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Part 1

(18351 Questions)

MRCPass

OnExamination

PassMedicine

ReviseMRCP

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1 st Edition

(2475 Questions)

Khalid Yusuf El-Zohry

Sohag Teaching Hospital - Egypt

elzohryxp@yahoo.com

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El-zohry MRCP Questions Bank (Part 1) - 2013

(For my personal use)

Contents

iLoJ&jO .8

dfijLj olbo .10

How to register for MRCP part 1.28

Reference ranges.31

MRCPass.33

[ Q: 1 ] MRCPass - Gastroenterology.35

[ Q: 141 ] MRCPass - Rheumatology.91

[ Q: 268 ] MRCPass - Respiratory.141

[ Q: 389 ] MRCPass - Nephrology.189

[ Q: 529 ] MRCPass - Neurology.243

[ Q: 682 ] MRCPass - Infectious disease.299

[ Q: 840 ] MRCPass - Haematology.365

[ Q: 999 ] MRCPass - Endocrinology.429

[ Q: 1155 ] MRCPass - Clinical pharmacology.487

[ Q: 1287 ] MRCPass - Cardiology.529

[ Q: 1412 ] MRCPass - Basic Science.573

[ Q: 1582 ] MRCPass - Dermatology.633

[ Q: 1611 ] MRCPass - Ophthalmology.645

[ Q: 1670 ] MRCPass - Psychiatry.667

[ Q: 1729 ] MRCPass - Statistics.687

[ Q: 1777 ] MRCPass - 2010 January.703

[ Q: 1876 ] MRCPass - 2010 May.745

[ Q: 1976 ] MRCPass - 2010 September.783

[ Q: 2076 ] MRCPass - 2011 January.825

[ Q: 2176 ] MRCPass - 2011 May.867

[ Q: 2275 ] MRCPass - 2011 September.913

[ Q: 2375 ] MRCPass - 2012 January.955

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Dedications

To my father,
my mother,
my wife,
my sons:

Abd El-Rahman,
Muhammed,
and Amr

To president Muhammad Mursi

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Take the first step, and your mind will mobilize all

its forces to your aid.

But

The first essential is that you begin

Once the battle is startled, all that is within and
without you will come to your assistance

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Experience of Dr. Mohamed Sabagh for MRCP part 1&2

MRCP parti, 2 written and ^ Mahmoud Abdel-Raheem Fathy j Heba Mohammed

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Dr. Kholid Yusuf El-Zohry - Sohog Teaching Hospital (01118391123)

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kumar or karla or oxoford handbook any of them is helpful
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MRCP Part 2

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A 30-year-old femalepresents with a one year history of galactorrhoea. She has been
receivingtreatment for hay fever, depression, obesity anddyspepsia.

Her investigationsreveal:

Full blood count Normal

Urea and electrolytes Normal

Prolactin 820 mU/l(<360)

Free thyroxine (T4) 18.3 pmol/l (10-22)

TSH concentration 2.1 mU/l (0.4-5)

Which one of thefollowing drugs is most likely to explain these findings?

(Please select loption)

1- Astemizole

2- Metoclopramide

3- Orlistat

4- Paroxetine

5- Ranitidine

Dr. Kholid Yusuf El-Zohry - Sohag Teaching Hospital (01118391123)

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An 80-year-old woman has a three month history of progressive numbness and unsteadiness of her
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On examination, thereis a mild spastic paraparesis, with brisk knee reflexes, ankle reflexes
arepresent with reinforcement, extensor plantars, sensory loss in the legs with asensory level at
T10, impaired joint position sense in the toes, and loss of vibration sense below the iliac crests.

Investigations wereas follows:

Haemoglobin 12.2 g/dL(12-16)

MCV 95 fL (80-96)

What is the mostlikely diagnosis ?

(Please select loption)

1- Anterior spinal artery occlusion

2- Dorsal meningioma

3- Multiple sclerosis

4- Subacute combined degeneration of the cord

5- Tabes dorsalis

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Which clinical feature is consistent with a diagnosis of VIPoma ?

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2- Hypoglycaemia

3- Hypokalaemia

4- Increased gastric acid seceretion

5- Provocation of VIP release by somatostatin

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the Internet! He asks your opinionon Laser Transmyocardial Revascularisation.

Which of the following statementsabout this technique is true?

A) avoids the need for major surgery

B) damages the endocardium

C) involves destruction of coronary stenoses

D) is of particular use in severe proximal coronary arterydisease

E) stimulatescollateral vessel formation

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The polymerase chain reaction (PCR) is used to amplify smallamounts of deoxyribonucleic acid
(DNA) for further analysis. First the DNAdouble helix must be split into two strands.

By which of the following is thisachieved?

(Please select 1 option)

6- Alkali solution

7- Centrifugation

8- DNA polymerase

9- Heating to nearly 100°C

10- Viral reverse transcriptase

Which one of the following statements concerning T lymphocytes is correct ?
(Please select 1 option)

1- Are infected byEpstein-Barr virus in infectious mononucleosis

2- Are the primary host response in bacterial infection

3- Compose the majority of lymphocytes in plasma

4- Produce IgG

5- T cell lymphoma has a better prognosis than B cell lymphoma

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A 75-year-old man has a history of chronic lymphocyticleukaemia. He has had treatment with
several courses of chemotherapy and hasnow been admitted to hospital with pneumonia.

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El-zohry MRCP Questions Bank (Port 1) - 2013

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His medical historyrevealed that he had suffered several previous upper respiratory tractinfections
over the previous six months.

Which ofthefollowing components of his immune system is likely to be deficient?

(Please select 1 option)

1- Complement

2- Immunoglobulin G

3- Macrophages

4- Mast cells

5- T lymphocytes

In which one of the following conditions is deoxyribonucleicocid (DNA) analysis the most useful
diagnostic test?

(Please select 1 option)

1- Adult polycystic kidney disease

2- Down's syndrome

3- Huntington's chorea

4- Hypertrophic obstructive cardiomyopathy

5- Klinefelter's syndrome

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Concerning immune cell antigen receptors, which ofthefollowing statements is false?

(Please select 1 option)

1- Affinity maturationof the B cell receptor is an important process initiated during the
primaryimmune response

2- IgD are surface receptors of B lymphocytes

3- In normal individuals T lymphocytes with T cell receptors(TCR) that recognise autoantigens
are all deleted to preventautoimmunity

4- TCRs with different antigen specificities can beco-expressed on a single T lymphocytes

5- The antigen specificity of the T cell receptor is generated during development

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Egyptians for MRCP part 1 ^ Heba Mohammed

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How to register for MRCP part 1

Egyptians for MRCP part 1 ^ farek Altohamy j Heba Mohammed

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Reference ranges

Reference ranges vary according to individual labs.
All values are for adults unless otherwise stated

Full blood count

Haemoglobin Men: 13.5-18 g/dl

Women: 11.5-16 g/dl
Mean cell volume 82-100 fl
Platelets 150-400 x 10 9 /l
White blood cells 4-11 x 10 9 /l |

Urea and electrolytes

Sodium 135-145 mmol/I
Potassium 3.5 - 5.0 mmol/I
Urea 2.0-7 mmol/I
Creatinine 55-120 umol/l
Bicarbonate 22-28 mmol/I

Liver function tests

Bilirubin 3-17 umol/l
Alanine transferase (ALT) 3-40 iu/l
Aspartate transaminase (AST) 3-30 iu/l
Alkaline phosphatase (ALP) 30-100 umol/l
Gamma glutamyl transferase (yGT) 8-60 u/l
Albumin 35-50 g/l
Total protein 60-80 g/l

Other haematology

Erythrocyte sedimentation rate (ESR)

Men: < (age / 2) mm/hr

Women: < ((age + 10) / 2) mm/hr

Prothrombin time (PT) 10-14 secs

Activated partial thromboplastin time (APTT)

25-35 secs

Ferritin 20-230 ng/ml

Vitamin Bi 2 200-900 ng/l
Folate 3.0 nmol/I
Reticulocytes 0.5-1.5%

Other biochemistry

Calcium 2.1-2.6 mmol/I
Phosphate 0.8-1.4 mmol/I
CRP < 10 mg/I

Thyroid stimulating hormone (TSH) 0.5-5.5
mu/I

Free thyroxine (T4) 9-18 pmol/l
Total thyroxine (T4) 70-140 nmol/I
Amylase 70-300 u/l
Uric acid 0.18-0.48 mmol/l

Arterial blood gases

pH 7.35-7.45
pC0 2 4.5 - 6.0 kPa
p0 2 10 -14 kPa

Lipids

Desirable lipid values depend on other risk
factors for cardiovascular disease, below is
just a guide:

Total cholesterol < 5 mmol/l
Triglycerides < 2 mmol/l
HDL cholesterol > 1 mmol/l
LDL cholesterol < 3 mmol/l

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MRCPass

WebSite: www.MRCPass.com
Total number of Questions: 2475

From Question number

Page

Gastroenterology

1-140

Rheumatology

141 - 267

Respiratory

268 - 388

Nephrology

389-528

Neurology

529-681

Infectious disease

682-839

Haematology

840 - 998

Endocrinology

999-1154

Clinical pharmacology

1155-1286

Cardiology

1287 -1410

Basic Science

1412-1581

Dermatology

1582 -1610

Ophthalmology

1611-1669

Psychiatry

1670-1728

Statistics

1729-1776

2010 January

1777-1875

2010 May

1876-1975

2010 September

1976-2075

2011 January

2076-2175

2011 May

2176-2274

2011 September

2275-2374

2012 January

2375 - 2475

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[ Q: 1 ] MRCPass - Gastroenterology

A 45 year old man presents with
acute, profuse, watery diarrhoea some after
returning from a holiday in Namibia.

Which one of the following is the most
appropriate treatment?

1- Metronidazole

2- Ciprofloxacin

3- Vancomycin

4- Prednisolone

5- Cefuroxime

Answer & Comments

Answer: 2- Ciprofloxacin

The most likely cause of travellers diarrhoea is
E. coli. Ciprofloxacin would cover for this as
well as shigella, salmonella and
Campylobacter. However, if giardiasis was
cultured in the stool then metronidazole is
recommended.

[ Q: 2 ] MRCPass - Gastroenterology

A 45 year old man has had long
standing jaundice, malaise and poor appetite.
Over the past 6 months he has lost 2 stones in
weight.

On examination he has palmar erythema,
jaundiced sclerae, spider naevi, hepatomegaly
and ascites.

His bloods reveal:

Bilirubin 50 mmol/I

ALT 150 U/l

ALP 240 U/l

Hep C core antibody Positive

Hep BsAg Negative

Hep A antibody Negative

3- Hepatocellular carcinoma

4- Hepatitis A infection

5- Infectious mononucleosis

Answer & Comments

Answer: 3- Hepatocellular carcinoma

30% of patients with hepatitis C develop
hepatocellular carcinoma over 30 years. 20%
develop cirrhosis over 20 years.

Hepatocellular carcinoma

[ Q: 3 ] MRCPass - Gastroenterology

A 72 year old woman with
longstanding hip osteoarthritis presents
complains of constipation and loose stool. She
undergoes a sigmoidoscopy. A rectal biopsy
shows pigment-laden macrophages in the
lamina propria.

What is the most likely cause?

1- Non-steroidal anti-inflammatory drugs

2- Crohn's disease

3- Diverticular disease

4- Whipple's disease

5- Laxative abuse

Answer & Comments

Answer: 5- Laxative abuse

What is the likely diagnosis?

1- Abnormal variant hepatitis C

2- Superimposed hepatitis E infection

The pigment laden macrophages suggest that
there is melanosis coli. The most common
association is with laxatives. To a lesser

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extent, melanosis coli is also associated with
ulcerative colitis.

Melanosis coli

[ Q: 4 ] MRCPass - Gastroenterology

A 40 year old man has symptoms of
lethargy, joint pains and jaundice which have
occurred over the past 8 months. Four years
later he became diabetic and was referred to
our hospital clinic. He was noted to be
pigmented.

Haemochromatosis was confirmed by an iron
saturation of 93.4%, a ferritin concentration of
1050 pg/l, and typical pre-cirrhotic changes in
a liver biopsy specimen.

What is the recommended management?

1- Venesection

2- Haemodialysis

3- Liver transplant

4- Phenoxybenzamine

5- Glucagon

Venesection is recommended when the serum
ferritin reading is over 1000?g/l. Venesection
can restore hypothalamic-pituitary-gonadal
and can reduce liver fibrosis.

[ Q: 5 ] MRCPass - Gastroenterology

A 50 year old patient has a 2 year
history of weight loss and diarrhoea. He also
gives a history of episodes of flushing. VIP
syndrome is considered by the admitting
physician.

Which one of the following is a feature of
VIPoma syndrome?

1- Hypoglycaemia

2- Hypokalaemia

3- Induction of VIP release by somatostatin

4- Anaemia

5- Increased gastric acid seceretion

Answer & Comments

Answer: 2- Hypokalaemia

VIPomas [vasoactive intestinal peptide (VIP)]
originate in amine precursor uptake and
decarboxylation (APUD) cells of the
gastroenteropancreatic endocrine system and
in adrenal or extra-adrenal neurogenic sites.

Features of VIP syndrome include watery
diarrhea (100%), hypochlorhydria (70% in
adults), hyperglycemia (20-50% in adults),
hypercalcemia (20-50% in adults), flushing
(20% in adults) and hypokalaemia due to
diarrhoea.

Answer & Comments

Answer: 1- Venesection

In haemochromatosis, the defect is due to
increased iron absorption, hence
hydroxypyridone orally helps chelate iron in
the gut. However, venesection is preferred
therapy and desferrioxamine infusion
(another iron chelator) can also be used.

Initial treatment is directed toward correcting
volume and electrolyte abnormalities by using
potassium chloride and sodium bicarbonate.
Octreotide controls diarrhea in 80% of cases.
Glucocorticoids reduce symptoms in 50% of
patients with VIPoma.

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Vipoma

[ Q: 6 ] MRCPass - Gastroenterology

A 45 year old man has returned from
holiday in Italy following several episodes of
bloody diarrhoea which had lasted over two
weeks. He has lost 2.5 kg in weight and has
occasional lower abdominal cramping
discomfort.

He also a painful swelling of his left elbow and
right knee.

What is the likely diagnosis?

1- Campylobacter infection

2- Coeliac disease

3- Tuberculosis

4- Ulcerative colitis

5- Gonococcal sepsis

Answer & Comments

Answer: 1- Campylobacter infection

Campylobacter infection is one of commomest
causes of infective diarrhoea.

Abdominal pain is often a feature of the
illness. Diarrhoea is often associated with
blood. Other causes of bloody diarrhoea are
salmonella & shigella.

[ Q: 7 ] MRCPass - Gastroenterology

A 22 year old man has recently

returned from India. He complains of fever,
rigors and headache.

On examination he had a temperature of
38°C, a blood pressure of 120/70 mmHg, a
pulse of 110 bpm. His abdomen was tender in
right upper quadrant.

Investigations showed:

Hb 10.5 g/dL

WBC 13.5 x 10 9 /L

Neutrophils 11.2 x 109/1

Platelets 360 x 10 9 /L

Blood film No malaria parasites seen

Aik Phos 420 U/L

AST 60 U/L

CRP 110 mg/L

Stool culture Negative

Chest x-ray: Small right pleural effusion

Which of the following investigations would be
of diagnostic value?

1- Ultrasound scan of abdomen

2- Anti endomysial antibody

3- Typhoid serology

4- Stool for ova, cysts parasites

5- Colonosocopy

Answer & Comments

Answer: 1- Ultrasound scan of abdomen

The ultrasound would determine if there is a
pyogenic liver abscess or amoebic liver
abscess. The clinical history with associated
pleural effusion suggests that an abscess
needs to be excluded (and drained if
necessary).

[ Q: 8 ] MRCPass - Gastroenterology

A 60 year old woman presents with
diarrhoea. She had a past history of
radiotherapy for ovarian cancer. Small
intestine biopsy reveals villous atrophy, crypt

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hypertrophy, chronic inflammatory cell
infiltrate of lamina propria and increase in
intraepithelial lymphocytes.

What is the likely diagnosis?

1- Radiation enteropathy

2- Coeliac disease

3- Ischaemic colitis

4- Crohn's disease

5- Tropical Sprue

Answer & Comments

Answer: 2- Coeliac disease

Histology of small bowel biopsy specimens
remains the "gold standard" for diagnosis.

Features recognised include villus atrophy,
crypt hyperplasia, degenerate surface
epithelial cells, and an increase in
intraepithelial lymphocytes.

[ Q: 9 ] MRCPass - Gastroenterology

A 60 year old man has a 5 day history
of abdominal pains and bloody diarrhoea. He
is unwell on admission. Blood pressure is
90/50 mmHg and he has a tender abdomen on
palpation.

His Hb is 9.0 g/dl, white cell count 11.0 x 10 9 /L
and platelet count is 80 x 10 9 /L Urea is 18
mmol/l and creatinine 250 pmol/l, sodium 137
mmol/l and potassium 5.5 mmol/l/ Blood film
shows red cell fragmentation and
thrombocytopenia.

Which of the following is most likely to confirm
the unifying diagnosis?

1- CT scan of the abdomen

2- Amoxycillin and metronidazole

3- Stool sample for E coli 0157

4- Mesenteric angiography to exclude
ischaemic colitis

5- Surgical laparotomy

Answer & Comments

Answer: 3- Stool sample for E coli 0157

The diagnosis is HUS (haemolytic uraemic
syndrome). The commonest causes are E coli
0157, but other precipitants are
Campylobacter, shigella and Clostridium. There
is classical renal failure, thrombocytopenia
(HUS-TTP) and evidence of microangiopathic
haemolysis on the blood film.

[ Q: 10 ] MRCPass - Gastroenterology

A 50 year old man has diabetes. He
has the following results:

Alanine aminotransferase 35 U/L

Aspartate aminotransferase 40 U/L

Fasting plasma glucose 7.4

Ferritin 500 ug/L, (15-300)

Which one of the following is an appropriate
investigation?

1- Transferrin saturation

2- Serum electrophoresis

3- Serum transferrin receptors

4- Liver biopsy

5- Urinary PBG

Answer & Comments

Answer: 1- Transferrin saturation

In hemochromatosis, the serum Fe is elevated
(> 300 mg/dL). The serumtransferrin

saturation is a sensitive parameter of
increased Fe and merits evaluation when >
50%. The serum ferritin is increased. Urinary
Fe excretion is markedly increased (> 2 mg/24
h) by the chelating drug deferoxamine (500 to
1000 mg IM based on the size of the patient),
and this has been used as a diagnostic test.

In addition, when the Fe content in the liver is
significantly increased, an MRI may reflect this
change. Liver biopsy had been the gold
standard in diagnosis; it now serves only to

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provide evidence of fibrosis (cirrhosis). Gene
assay (Homozygosity C282y mutations) is also
an excellent diagnostic test.

[ Q: 11 ] MRCPass - Gastroenterology

A 65 year old woman presents with
dysphagia and intermittent vomiting.
Endoscopy shows a tight lower oesophageal
sphincter suggestive of achalasia.

Which of the following medical therapies is
most effective?

1- Diltiazem

2- Bismuth

3- Glyceryl trinitrate

4- Botulinum toxin

5- Glypressin

Answer & Comments

Answer: 4- Botulinum toxin

Botulinum injections are most effective of all
the options for relieving a lower oesophageal
sphincter restriction which leads to achalasia.
Nifedipine, nitrates or sildenafil can also be
used, but are less effective.

[ Q: 13 ] MRCPass - Gastroenterology

A 50 year old presents with tiredness
and heavy periods. She is known to drink large
amounts of alcohol.

Her investigations reveal:

Haemoglobin 7.3 g/dl
MCV 72 fL

white cell count 7.5 x 10 9 /L

platelet count 250 x 10 9 /L

serum ferritin 7 pg/L, (15-300)

She was commenced on oral iron therapy one
month later but her haemoglobin
concentration was 7.8 g/dl.

What is the likely cause of the failure of her
haemoglobin to respond?

1- Folate deficiency

2- Poor compliance therapy

3- Sideroblastic anaemia

4- Alcoholism

5- Irreversible cause of iron deficiency

Answer & Comments

Answer: 2- Poor compliance therapy

[ Q: 12 ] MRCPass - Gastroenterology

Which of the following factors
decreases large intestinal motility?

1- Lactulose

2- Parasympathetic activity

3- CCKPZ

4- Gastric Distension

5- Anticholinergic agents

Answer & Comments

Answer: 5- Anticholinergic agents

Anticholinergic agents, e.g. atropine, reduce
intestinal motility. All the other agents
increase intestinal motility.

The likely explanation failure of an iron
deficiency anaemia to respond iron therapy in
a patient with heavy periods is poor
compliance.

[ Q: 14 ] MRCPass - Gastroenterology

A 55 year old man with a history of
heavy alcohol intake presents with acute
confusion. A diagnosis of hepatic
encephalopathy is made and treatment with
lactulose is commenced.

What is its mode of action in this context?

1- Reduces absorption of chlordiazepoxide

2- Inhibits proliferation of ammonia forming
organisms in the gut

3- Absorbed from gut

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4- Contraindicated in diabetes mellitus

5- Causes hypermagnesaemia

Answer & Comments

Answer: 2- Inhibits proliferation of ammonia
forming organisms in the gut

The syndrome most often occurs in patients
with underlying thrombotic diathesis,
including myeloproliferative disorders such as
polycythemia vera and paroxysmal nocturnal
hemoglobinuria, pregnancy, tumors, chronic
inflammatory diseases, clotting disorders, and
infections.

Lactulose is used in patients with
cirrhosis/hepatic encephalopathy. It limits the
proliferation of ammonia forming gut
organisms and increases clearance of protein
load in gut. It causes hypomagnesaemia.
Chlordiazepoxide absorption is not affected.

[ Q: 15 ] MRCPass - Gastroenterology

A 35 year old lady has sudden onset
right upper quadrant pain and abdominal
distension. She was well until 5 weeks ago,
when over several days she rapidly developed
abdominal distension and pain. She was also
nauseous and vomiting.

On examination, temperature was 37.1°C, her
JVP was not raised and breath sounds were
clear. Abdominal examination revealed tender
hepatomegaly, jaundice and gross ascites.
There was also bilateral ankle oedema.

Whot is the likely diagnosis?

1- Dubin Johnson syndrome

2- Gilbert's syndrome

3- Budd Chiari syndrome

4- Lymphoma

5- Myeloma

Doppler ultrasonography, as was used in this
case, is the most effective primary initial
screening method. CT and magnetic
resonance angiography are both more
sensitive than ultrasonography. The gold
standard for diagnosis is hepatic venography,
which should be performed when there is a
high index of clinical suspicion and the results
of noninvasive testing are either equivocal or
negative.

[ Q: 16 ] MRCPass - Gastroenterology

A 40 year old man who usually drinks
only 2 units of alcohol a day went on an
alcohol binge with his friends. On that day, he
vomited 10 times and was brought to hospital
feeling very unwell. He has not previously had
any symptoms of dyspepsia or abdominal
pains. During physical assessment, he vomits a
large bowlful of blood.

Whot is the likely couse of his hoemetemesis?

1- Oesophageal varices

2- Duodenal ulcer

3- Mallory Weiss tear

4- Gastritis

5- Gastric outlet obstruction

Answer & Comments

Answer: 3- Budd Chiari syndrome

Budd-Chiari syndrome is a condition induced
by thrombotic or nonthrombotic obstruction
to hepatic venous outflow. The classic clinical
triad of abdominal pain, hepatomegaly, and
ascites was described by Budd in 1845, and
the histopathological features were described
by Chiari at the turn of the 20th century.

Answer & Comments

Answer: 3- Mallory Weiss tear

A Mallory-Weiss tear occurs in the mucous
membrane typically in the lower oesophagus.
Mallory-Weiss tears are usually caused by
forceful or prolonged vomiting or coughing.
They may also be caused by epileptic
convulsions.

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The tear may be followed by vomiting bright
red blood or by passing blood in the stool. The
incidence is 4 in 100,000 people.

Mallory Weiss tear

Investigations reveal:

Hb 8.5 g/dl

MCV 85 fl

WCC 6 x 10 9 /l

Iron 11 (14-29) pmol/l

Ferritin 20 (15-200) pmol/l

Folate 2 (3-20) ?g/l

What investigation should be done?

1- Ultrasound of abdomen

2- Small bowel biopsy

3- Smooth muscle antibodies

4- ERCP

5- Rigid sigmoidoscopy

[ Q: 17 ] MRCPass - Gastroenterology

A 30 year old lady has altered bowel
habit. At the gastroenterology clinic, her
symptoms are reviewed. She has a 2 year
history of bloating and abdominal pains. Some
weeks she is constipated and during others
she has diarrhoea.

What is the likely diagnosis?

1- Whipple's disease

2- Tropical sprue

3- Coeliac disease

4- Irritable bowel syndrome

5- Ulcerative colitis

Answer & Comments

Answer: 4- Irritable bowel syndrome

Weight loss, fevers and blood in the stool are
features which suggest a different organic
cause other than irritable bowel syndrome.

[ Q: 18 ] MRCPass - Gastroenterology

fit

# A 60 lady has symptoms of
intermittent abdominal pain and loose stool
which have occurred over 1 year.

Answer & Comments

Answer: 2- Small bowel biopsy

The combined iron and folate deficiency
anaemia as well as symptoms suggestive of
malabsorption makes celiac disease a likely
diagnosis. Small bowel biopsy may show
partial or subtotal villous atrophy. Anti
endomysial antibodies will also be helpful.

[ Q: 19 ] MRCPass - Gastroenterology

A 25 year old bartender has had
abdominal pains and loose stools for 3 years.
He also has symptoms of myalgia and
profound fatigue. He mentions that the
abdominal pains are often worse after he has
bread.

Anti endomysial antibody is positive. An
enzyme-linked immunosorbent assay test was
conducted and it showed positive reactions to
gluten, albumin, lactose, barley, and rye.

What is the diagnosis?

1- Diverticulosis

2- Tropical sprue

3- Ulcerative colitis

4- Crohn's disease

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5- Coeliac disease

Answer & Comments

Answer: 5- Coeliac disease

Signs of coeliac disease include fatigue, weight
loss, diarrhoea, arthralgia and myalgia. The
"gold standard" for diagnosing celiac disease is
through a jejunal mucosal biopsy sample to
measure the extent of the damage. Another
method is the enzyme-linked immunosorbant
assay (ELISA).

Celiac disease patients cannot tolerate gluten,
a protein found in the grains wheat, rye, and
barley. In order to preserve their
gastrointestinal integrity, patients with celiac
disease need to take extra precaution when
selecting foods.

[ Q: 20 ] MRCPass - Gastroenterology

A 55 year old man is suspected of
having a duodenal ulcer recurrence despite
being on omeprazole.

Which of the following is the most sensitive
test in detecting ongoing infection with
Helicobacter pylori?

1- The (13C) urea breath test

2- The urease test on a gastric biopsy

3- A gastric fundal biopsy culture

4- Helicobacter pylori serology

5- Stool culture

Answer & Comments

Answer: 1- The (13C) urea breath test

The urea breath test is expensive but has up
to 98% sensitivity. The gastric biopsy culture
has high specificity but sensitivity of 90%.
Histology of gastric biopsy (not listed above)
has both high sensitivity and specificity.

[ Q: 21 ] MRCPass - Gastroenterology

A 35 year old lady presents with
abdominal pain to the GP who suspects
irritable bowel syndrome.

Which of the following is a recognised feature
of irritable bowel syndrome?

1- Lactase deficiency

2- Bloating

3- A past history of dysentery

4- Late development of carcinoma of the
colon

5- Diarrhoea but not constipation

Answer & Comments

Answer: 2- Bloating

Abdominal pain relieved by defecation,
bloating, as well as alternating bowel habits is
common.

[ Q: 22 ] MRCPass - Gastroenterology

A 28 year old intravenous drug user
complains about severe epigastric pains,
nausea and vomiting. He has upper Gl
endoscopy which shows small areas of
ulceration and white plaques.

Which of the following is the best treatment
option ?

1- Metronidazole

2- Amoxycillin

3- Ranitidine

4- Fluconazole

5- Aciclovir

Answer & Comments

Answer: 4- Fluconazole

This is a patient with possible HIV who has
oesophageal candidiasis. Fluconazole,
ketoconazole and itraconazole can be used.

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[ Q: 23 ] MRCPass - Gastroenterology

A couple develops profuse vomiting
after attending a dinner in a Chinese
restaurant. They ate at 7 pm but became ill
early in the next morning.

Whot is the likely infective organism?

1- Bacillus cereus

2- Salmonella enteriditis

3- Bacillus anthracis

4- Clostridium perfringens

5- E. Coli

moist cooked protein foods and rice (hence its
association with Chinese takeaways).

[ Q: 24 ] MRCPass - Gastroenterology

A 36 year old lady has noticed mild
jaundice, worsening joint pains and is
complaining of itching on her skin for the past
8 months. On examination, she has palpable
hepatomegaly and a bronze pigmentation on
her skin.

Her liver function tests show a bilirubin of 25
pmol/l, ALT 100 U/l, ALP 480 U/l. ANA is
negative, anti-mitochondrial antibody is
positive at 1/320.

Which of the following medications is helpful?

1- Desferrioxamine

2- Hydrocortisone

3- Propanolol

4- Ursodeoxycholic acid

5- Tranexemic acid

Answer & Comments

Answer: 4- Ursodeoxycholic acid

Answer & Comments

Answer: 1- Bacillus cereus

Bacillus Cereus food poisoning is a
gastrointestinal intoxication caused by toxins
produced by the Bacillus Cereus bacteria.
There are two types of toxin, - the Diarrhoeal
and the Emetic toxins.

Symptoms with the diarrhoeal toxin are
nausea, cramplike abdominal pains and
watery diarrhoea.

The diagnosis is confirmed by a laboratory test
on a faecal specimen. Bacillus cereus exists in
normal bacterial and spore forms in foods.
The normal form is inactivated by cooking, but
most illness is a result of the multiplication of
spores during inadequate refrigeration of

Primary biliary cirrhosis is described. Liver
transplantation does not cure the condition.
Histology shows white cell damage to the
biliary epithelium with non necrotising
granuloma formation in the portal triad.

Ursodeoxycholic acid lowers serum bilirubin
and symptoms of itching, and prolongs the
progression tow ards requirement for liver
transplantation. IgM levels are particularly
high in PBC.

[ Q: 25 ] MRCPass - Gastroenterology

•Sf -

# A 45 year old man has a diagnosis of
coeliac disease. He presents with a one month
history of intermittent, colicky, central
abdominal pain and weight loss of 5 kg. There
is positive faecal occult blood.

What is the most appropriate investigation?

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1- Duodenal biopsy

2- Barium enema

3- Surgical exploration

4- CT scan of abdomen

episode may have been precipitated by
intravenous dextrose administration which
exhausted his vitamin B reserves. B vitamins
should be administered to all alcoholic
patients requiring dextrose.

5- Colonoscopy

Answer & Comments

Answer: 5- Colonoscopy

Colonoscopy is necessary to exclude a colonic
carcinoma. There is a relatively high
prevalence of colorectal neoplasia among
older patients with coeliac disease who can
present with iron deficiency or altered bowel
habit.

[ Q: 26 ] MRCPass - Gastroenterology

A 60 year old man has symptoms of
lethargy and vomiting. He drinks 10 pints of
beer a day. He was started on an intravenous
glucose infusion and chlordiazepoxide. For a
day, he symptomatically improved. However,
the next day, he became confused and started
vomiting several times. He also had diplopia
and was unable to stand.

What is the likely diagnosis?

[ Q: 27 ] MRCPass - Gastroenterology

A 30 year old psychology lecturer has
deranged liver function tests. She also has
jaundice, pruritus and xanthelasmata.

Blood tests reveal elevated levels of
conjugated bilirubin, alkaline phosphatase,
gamma-glutamyltranspeptidase and positive
anti-mitochondrial antibody. She seeks advice
about the associations of the disease.

Which one of the following is likely to be
associated?

1- Raised IgA

2- Osteomalacia

3- Hyperparathyroidism

4- Nephrotic syndrome

5- Vitamin A deficiency

Answer & Comments

Answer: 2- Osteomalacia

1- Delirium tremens

2- Hepatic encephalopathy

3- Cerebellar stroke

4- Vitamin B deficiency

5- Pancreatitis

Answer & Comments

Answer: 4- Vitamin B deficiency

Wernicke's encephalopathy is a neurologic
disorder of acute onset caused by a thiamine
deficiency. The condition is characterized by
ocular abnormalities, ataxia, and a global
confusional state.

Wernicke's encephalopathy results from a
deficiency in vitamin B-l (ie, thiamine). The

The diagnosis is primary biliary cirrhosis (PBC).
It is based on a combination of findings
including cholestatic liver enzymes, a positive
antimitochondrial antibody (AMA), and
characteristic liver biopsy findings. Elevated
serum alkaline phosphatase of liver origin is
the most common laboratory finding. Fatigue,
jaundice, pruritus and xanthelasmata are
other features of primary biliary cirrhosis.

In the disease, IgM is raised. Primary biliary
cirrosis is associated with autoimmune
conditions such as scleroderma and Sjogren's
syndrome. These conditions are also
associated with distal RTA (type 1). There is
xanthelasma formation due to impaired
cholesterol excretion and also osteomalacia
due to impaired Vitamin D absorption.

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[ Q: 28 ] MRCPass - Gastroenterology

A 25 year old man presents with pain
over the right side of the abdomen, diarrhoea,
poor appetite and weight loss. He is pyrexial
with a temperature of 39°C. He has oral
apthous ulcers and a tender right lower
quadrant in the abdomen. Rectal examination
is normal.

His Hb is 12.5g/dl, WCC 14 x 10 9 /L and
platelets 550 x 10 9 /L Urea is 8 pmol/l and
creatinine is 90 pmol/l, CRP is 105 mg/I.

Which of the following is the best test to
confirm the diagnosis?

1- Stool cultures

2- Barium meal and follow through

3- Ultrasound of abdomen

4- Colonoscopy

5- Surgical laparotomy

Strictures seen on the Barium Follow through

in Crohn's disease

Answer & Comments

Answer: 2- Barium meal and follow through

The likely diagnosis is Crohn's disease and a
barium follow through is the best test to
confirm this. Behcet's disease and Yersinia
colitis can also present with raised
inflammatory markers, oral ulceration and
right sided abdominal pathology.

^ [ Q: 29 ] MRCPass - Gastroenterology

ii -

# A 52 year old male presents with
general weakness. He drinks approximately 20
units of alcohol each week and smokes 10
cigarettes daily. Examination reveals jaundice,
numerous spider naevi and he has a
temperature of 37.5°C. Abdominal
examination reveals hepatosplenomegaly.

Investigations show :

Bilirubin 140 micromol/L (1-22)

Alkaline phosphatase 525 iu/l (45-105)

AST 178 iu/l (1-31)

Albumin 28 g/L (37-49)

Hepatitis B virus surface antigen - negative

Hepatitis B virus e antigen - negative

Hepatitis B virus e Antibody- positive

Hepatitis B core Antigen (anti-HBc) - positive

Hepatitis B virus DNA - undetectable

What is the likely diagnosis?

1- Chronic hepatitis D (delta) infection

2- New hepatitis A infection

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3- Alcoholic liver disease

4- Chronic hepatitis B infection

5- New hepatitis C infection

Answer & Comments

Answer: 4- Chronic hepatitis B infection

A negative HbsAg and HbeAg, along with
positive hepatitis B antibodies (anti-HBc)
would suggest past or chronic infection.

^ [ Q: 30 ] MRCPass - Gastroenterology

fh -

# A 35 year old man presents with 2
bowls full of haemetemesis. He drinks 10 pints
of beer a day and has done so for 10 years.
Upper Gl endoscopy reveals oesophageal
varices.

Which of the following is effective in reducing
the rotes of rebleeding in the future?

1- Lisinopril

2- Propanolol

3- Simvastatin

4- Ranitidine

5- Naproxen

Answer & Comments

Answer: 2- Propanolol

Beta blockers (propanolol, nadolol), nitrates,
vasopressin analogues and somatostatin
analogues can be used for reducing rebleeding
in oesophageal varices.

[ Q: 31 ] MRCPass - Gastroenterology

A 30 year old woman who has been
on the contraceptive pill presents with
abdominal pain and distension of 5 days
duration. On examination she has no stigmata
of chronic liver disease. She has distended
veins over the anterior abdominal wall. She
also has ascites, an enlarged tender palpable
liver with absent hepato-jugular reflux.

Her ankles are oedematous.

Whot is the diagnosis?

1- Congestive cardiac failure

2- Antiphospholipid syndrome

3- Fatty liver

4- Budd Chiari syndrome

5- Pulmonary hypertension

Answer & Comments

Answer: 4- Budd Chiari syndrome

Budd-Chiari syndrome is thrombosis of the
hepatic vein, the major vein that leaves the
liver. Most patients have an underlying
thrombotic tendency. About 10% have
polycythemia vera, and about 10% have been
on the OCP. The most common symptoms in
Budd-Chiari syndrome are ascites and
jaundice.

[ Q: 32 ] MRCPass - Gastroenterology

A 25 year old woman with cystic
fibrosis presents with abdominal pain. The
abdominal pain is colicky and localised in the
lower abdomen.

On examination, she was pyrexial and
tachycardic. Her abdomen was distended.
There was guarding and bowel sounds were
present.

Which of the following is likely to be the
couse?

1- Renal Calculi

2- Ulcerative colitis

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3- Meconium Ileus Equivalent Syndrome

4- Pyelonephritis

5- Irritable Bowel Syndrome

Answer & Comments

Answer: 3- Meconium Ileus Equivalent
Syndrome

Answer & Comments

Answer: 4- Cholestyramine

The patient has had resection of the terminal
ileum and the cause of the diarrhoea is likely
to be Bile Acid Malabsorption (BAM). Bile acid
sequestrants such as cholestyramine should
help the symptoms of persistent diarrhoea.

Meconium Ileus is the earliest clinical
manifestation of cystic fibrosis (CF) and occurs
in approximately 16% of patients with CF.
Meconium in patients with ileus has higher
protein and lower carbohydrate concentration
than that in control populations.

Signs of peritonitis include tenderness,
abdominal wall edema, distension, and clinical
evidence of sepsis. A palpable mass may
indicate pseudocyst formation. Surgical
exploration is indicated for patients with
progressive distension, signs of peritonitis, or
clinical deterioration.

Complicated Meconium Ileus requires
resection more often than simple cases and
always requires temporary stomas.

^ [ Q: 34 ] MRCPass - Gastroenterology

A -—

# A 45 year old man has had a 5 year

history of severe sharp, epigastric pains and

diarrhoea. He gets 2-3 episodes of these

symptoms a day. His GP has prescribed proton

pump inhibitors which has helped partly, but

he still complains that the symptoms are

severe.

Which one of the following might confirm the
diagnosis?

1- Amylase

2- ERCP

3- C-peptide

4- Insulin

5- Gastrin level

[ Q: 33 ] MRCPass - Gastroenterology

A 40 year old woman has previously
had a right hemicolectomy and resection of 30
cms of terminal ileum for ileocaecal Crohn's
disease. She has persistent diarrhoea, which is
not explosive. She does not have abdominal
pain, bloating, or loss of weight. Investigations
have failed to demonstrate evidence of
recurrent Crohn's disease.

Which is the best therapy for the symptoms?
1- Prednisolone

Answer & Comments

Answer: 5- Gastrin level

The diagnosis is likely to be Zollinger Ellison
syndrome which is frequently secondary to a
gastrinoma. Gastrin levels are significantly
elevated. The secretin test can help to confirm
the diagnosis. There is increased gastrin
elevation (greater than 200 pg/mL) in a
positive test after secretin is given
intravenously.

2- Mesalazine

3- Azathioprine

4- Cholestyramine

5- Loperamide

There is an association with the MEN 1
syndrome, so calcium levels should be
checked (to screen for a parathyroid
adenoma).

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[ Q: 35 ] MRCPass - Gastroenterology

A 42 year old man has a diagnosis of
Ulcerative Colitis. He was incidentally found to
have positive anti smooth muscle antibodies
by the GP who sent an autoimmune screen.

Which is the next recommended test for this
patient?

1- CT of the abdomen

2- Colonoscopy

3- ESR

4- Endoscopy

5- Liver function tests

Answer & Comments

Answer: 5- Liver function tests

The features are suggestive of autoimmune
hepatitis. Liver function tests may
demonstrated eleveated levels of bilirubin,
AST and ALT. A liver biopsy may then be
warranted.

[ Q: 36 ] MRCPass - Gastroenterology

f -

# A 35 year old man has chronic liver
disease secondary to hepatitis. He comes on
having had a depressive episode but also feels
tired and unw ell. He reveals that he has had a
bottle of wine a day for a week.

On examination he has gross abdominal
distension. A peritoneal tap is done. Results
from the tap show that it has albumin of 25
g/l, LDH of 320 U/l, glucose 3.5 mmol/I (serum
glucose 6.5) and a white cell count of 700 per
mm * 1 2 3 (90% neutrophils).

What is the diagnosis?

1- Acute reactivation of hepatitis B

2- Tuberculous peritonitis

3- Alcoholic liver disease decompensation

4- Chylous ascites

5- Spontaneous bacterial peritiontis

Answer & Comments

Answer: 5- Spontaneous bacterial peritiontis

A white cell count of > 350 mm 3 5 is diagnostic
of spontaneous bacterial peritonitis. There is
underlying cirrhotic liver disease and this
should always be considered related to
decompensation.

[ Q: 37 ] MRCPass - Gastroenterology

A 60 year old male presents with a
two month history of shorness of breath,
weight loss and lethargy. He looks pale and is
jaundiced.

Investigations show :
Haemoglobin 6 g/dL

MCV 106 fL

White cell count 2.2 x 10 9 /L
Platelets 60 x 10 9 /L
Urinalysis: Increased urobilinogen.
What is the next appropriate test?

1- Coomb's test

2- Colonoscopy

3- Vitamin Bi 2 concentration

4- Bone marrow aspirate

5- Reticulocyte count

Answer & Comments

Answer: 3- Vitamin Bi 2 concentration

The clinical picture is one of megaloblastic
anaemia. B12 and folate measurement is the
first test to confirm this, and then other tests
such as blood film and marrow aspirates can
be done to investigate the cause.

[ Q: 38 ] MRCPass - Gastroenterology

A 30 year old man had previous
bowel resection for acute abdomen. He
continues to have frequent episodes of bloody
diarrhea and abdominal pain.

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Which one of the following is an X-ray change
which suggests Ulcerative Colitis?

1- Cobblestones

2- Skip lesions

3- Loss of haustral pattern

4- Rose thorn ulcers

3- Gastric biopsy

4- 24 hour oesophageal pH study

5- Amylase

Answer & Comments

Answer 4- 24 hour oesophageal pH study

5- Strictures

Answer & Comments

Answer: 5- Strictures

Loss of haustral pattern, lead pipe, and
shortened colon on the X ray, suggests
ulcerative colitis.

In Crohn's disease, transmural inflammation
with formation of fissures, ulcers and
granulomata, and cobblestone appearance are
seen.

Loss of haustral pattern in Ulcerative Colitis (X

ray)

[ Q: 39 ] MRCPass - Gastroenterology

A 45 year old asian man presents
with epigastric pains of burning nature. This
was worst at night.

He was prescribed Gaviscon for a year and but
this did not relieve his symptoms entirely. He
had an endoscopy which did not show any
significant abnormalities 3 months ago.

Which is the best test for father investigation?

1- Repeat endoscopy

2- Urease breath test

24 hour oesophageal pH study is the
investigation of choice for severe symptoms
suggestive of oesophageal reflux.

[ Q: 40 ] MRCPass - Gastroenterology

A 30 year old man has had a 10 year
history of chronic diarrhea. He has developed
episodes of abdominal pain after eating wheat
products, and is suspected of having celiac
disease.

Which one of the following is most likely to be
associated?

1- Increased serum ferritin

2- Osteomalacia

3- Anti double stranded DNA antibodies

4- Anal ulcers

5- Anti-Ro antibodies

Answer & Comments

Answer: 2- Osteomalacia

Celiac disease usually presents with iron
deficiency. Poor calcium absorption can result
in osteomalacia. Celiac disease can cause
mouth ulcers. Anti gliadin and anti endomysial
antibodies are associated.

[ Q: 41 ] MRCPass - Gastroenterology

A 45 year old lady has rectal bleeding
during bowel movements for 10 weeks. She
has severe lower abdominal pains. Her
appetite is poor and she has also lost 7 kg in
weight. On examination she has a tender left
lower abdomen and loud bowel sounds. Her

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abdomen is not distended. Rectal examination
reveals small streak of blood.

Investigations:

Hb is ll.lg/dl WCC 13.5 x 10 9 /L

platelets 600 x 10 9 /L urea 6 mmol/l

creatinine 100 pmol/l CRP 80 mg/I

A rigid sigmoidoscopy shows inflammatory
changes with ulceration and areas of bleeding.

Which of the following treatment options is
the best at present?

1- Intravenous hydrocortisone

2- Amoxycillin and metronidazole

3- 5-aminosalicylate given intravenously

4- Anti-TNFa antibody infusion

5- Intravenous gamma globulin

Answer & Comments

Answer: 1- Intravenous hydrocortisone

The features are consistent with colitis,
probably on a background of likely ulcerative
colitis. Steroids are used in severe cases of
colitis. If there are mild episodes of colitis then
5-aminosalicylates such as sulfasalazine can be
used. Anti TNF a antibody is used for severe
Crohn's disease.

Ulcerative Colitis

[ Q: 42 ] MRCPass - Gastroenterology

A 45 year old man is referred to the
hospital for assessment. Over the past year he
has been complaining of joint paints and was
thought to have osteoarthritis. 6 months
earlier, he noted gradual onset of fatigue,
decreased libido, and erectile dysfunction. He
has also been progressively breathless. He did
not have a cough, a fever, night sw eats, or
visual changes.

On physical examination, the patient was a
thin but well-developed man who was not in
distress. The blood pressure was 100/60 mm
Hg, and the heart rate 88 beats per minute.
The skin was tanned, with no spider angiomas
or palmar erythema. The abdominal
examination revealed palpable hepatomegaly
and he was mildly jaundiced. The testicles
were each estimated to be 18 ml without
masses, and the prostate examination was
normal.

Blood results show :
sodium 135 mmol/l
potassium 4.5 mmol/l
urea 5 mmol/l
creatinine 100 pmol/l
ALT 120 (5-35) U/l
AST 135 (1-31) U/l
ALP 132(20-120) U/l
Bilirubin 36 (1-22) pmol/l
Albumin 38 (37-49) g/l
What is the diagnosis?

1- Multiple Endocrine Neoplasia type II

2- Carcinoid syndrome

3- Primary biliary cirrhosis

4- Haemochromatosis

5- Amyloidosis

Answer & Comments

Answer: 4- Haemochromatosis

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A combination of hepatomegaly, diabetes, and
hyperpigmentation, reflecting parenchymal
iron loading of the liver, pancreas, and skin is
suggestive of haemochromstosis.

In haemochromatosis , joint deposition of iron
occurs, causing arthropathy. Increased iron
deposition in the skin stimulates increased
melanin production, and may cause a bronze /
tan skin. There is an increased incidence in
males. Haemochromatosis is a recognised
cause of restrictive cardiomyopathy which has
caused this patient to be breathless.

Myocardial cells with excessive iron
deposition (stained blue)

[ Q: 43 ] MRCPass - Gastroenterology

An obese 55 year old woman with
Type II diabetes is referred as she has been
found to have raised ALT and AST levels. She
does not have a history of pruritus or
jaundice. She is not on any medication and
does not take alcohol. On examination, she
has a smooth hepatomegaly of 3 cm edge.
There are no xanthelasmata and she does not
have signs of chronic liver disease.

What is the likely diagnosis?

1- Non-alcoholic fatty liver disease

2- Neuroacantocythosis

3- Chronic hepatitis

4- Hepatocellular carcinoma

5- Hepatorenal syndrome

Answer & Comments

Answer: 1- Non-alcoholic fatty liver disease

This diagnosis is non-alcoholic fatty liver
disease. The mildest type is simple fatty liver
(steatosis), an accumulation of fat within the
liver that usually causes no liver damage. This
disease is usually nonprogressive and rarely
causes liver cirrhosis. A potentially more
serious type, nonalcoholic steatohepatitis
(NASH), is associated with liver fibrosis.
Nonalcoholic fatty liver disease affects more
women than men, and is associated with
insulin resistance/diabetes and obesity.

[ Q: 44 ] MRCPass - Gastroenterology

A 46 year old man is known to have
alcoholic liver cirrhosis. He drinks 60 units of
alcohol per week. He presents unwell and
confused. Temperature is 38 C and blood
pressure is 96/50 mmHg. Abdominal palpation
reveals hepatomegaly and ascites.

What should be done next?

1- Albumin infusion

2- Blood cultures

3- Diagnostic ascitic tap

4- Liver biopsy

5- Transjugular intrahepatic shunting

Answer & Comments

Answer: 3- Diagnostic ascitic tap

There is a high chance of spontaneous
bacterial peritonitis in this patient with
cirrhotic liver disease. When analysis of ascitic
fluid reveals a white blood cell count of more
than 250 cells/cc, SBP is likely. Cefotaxime
should be commenced after a tap is done and
blood cultures are sent.

[ Q: 45 ] MRCPass - Gastroenterology

A 60 year old man complains of a 6
month history of lethargy, fever, weight loss,

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arthralgia and diarrhoea. Jejunal biopsy
reveals flattened mucosa with evidence of
periodic acid Schiff (PAS) positive
macrophages.

What is the diagnosis?

1- Tuberculosis

2- Tropical sprue

3- Whipple's disease

4- Helminthic infection

5- Ulcerative colitis

Answer & Comments

Answer: 3- Whipple's disease

Whipple's disease can affect any organ, but
predominantly affects the small bow el,
causing a malabsorption syndrome. The
organism (Tropheryma whippeii) can be
identified both between within abnormal
macrophages, which stain with PAS.
Treatment is with a prolonged course of
antibiotics eg. Iv penicillin and streptomycin 2
weeks, followed by 1 year of doxycycline.

Histology showing Whipple's disease

[ Q: 46 ] MRCPass - Gastroenterology

A 45 year old man has painless
jaundice. He has pale stools and dark urine.
On examination he is deeply jaundiced and
has scratch marks all over his body. On

palpation of the abdomen Courvoisier's sign is
positive.

Where is the level of biliary obstruction?

1- Bile canaliculi

2- Intrahepatic ducts

3- Hepatic duct

4- Accessory duct

5- Common bile duct

Answer & Comments

Answer: 5- Common bile duct

Courvoisier's sign is a palpable distended gall
bladder on examination of the abdomen.
Obstruction below the level of the cystic duct
causes this, probably due to carcinoma of the
pancreas.

[ Q: 47 ] MRCPass - Gastroenterology

A 35 year old woman presents with
abdominal pain, weight loss, diarrhoea and
mouth ulcers. Full blood count reveals
normocytic normochromic anaemia,
inflammatory markers are raised, and
biochemical investigation reveals a raised
alkaline phosphatase. Barium followthrough
shows terminal ileal inflammatory disease.

Long term remission may be maintained by
the use of which of the following drugs?

1- Mesalazine

2- Prednisolone

3- Azathioprine

4- Ciclosporin

5- Infliximab

Answer & Comments

Answer: 3- Azathioprine

Remission of Crohn's disease may be achieved
by the use of steroids, elemental diet, surgery
or Infliximab. Mesalazine may maintain
remission if induction has been achieved by

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surgery and if an 8-w eek course of
metronidazole is administered. In other
scenarios, the most useful drug to maintain
remission is azathioprine.

[ Q: 48 ] MRCPass - Gastroenterology

A 55 year old woman presents with
an 2 month history of diarrhoea with no blood
or mucous, colicky abdominal pain, vomiting
and 1 stone weight loss.

She has a history of arthritis for which she
takes diclofenac regularly. On examination she
was afebrile and looked pale. The abdomen
was diffusely tender but soft. Bowel sounds
were normal and rectal examination was
normal.

Investigations showed: Hb 8.5 g/dL, MCV 68 fl,
CRP 160, coeliac antibodies negative.
Colonoscopy revealed several areas of
superficial ulceration in the ascending colon.
Biopsies from these areas showed non-specific
inflammation.

What is the likely diagnosis?

1- Ulcerative colitis

2- Crohn's disease

3- Non-steroidal anti-inflammatory drug
colopathy

4- Coeliac disease

5- Tropical sprue

Answer & Comments

Answer: 3- Non-steroidal anti-inflammatory
drug colopathy

NSAID-colopathy can mimic Crohn's and
ulcerative colitis. Presenting symptoms and
signs include iron-deficiency anaemia and
crampy abdominal pain, alteration of bowel
habit, weight loss, nausea and vomiting.
Symptoms usually resolve with
discontinuation of the drugs.

[ Q: 49 ] MRCPass - Gastroenterology

A 65 year old ex-publican presented
to his GP complaining of difficulty
swallowing for the past two months. The
difficulty started several weeks ago with food
sticking. He also complained more recently of
pain on swallowing.

An OGD and biopsy confirms adenocarcinoma
of the oesophagus.

Which underlying condition is associated?

1- Alcoholism

2- Oesophageal candidiasis

3- Ulcerative colitis

4- Plummer vinson syndrome

5- Tropical sprue

Answer & Comments

Answer: 4- Plummer vinson syndrome

Plummer Vinson syndrome causes iron
deficiency anaemia and post cricoid
oesophageal web and achalasia.

There is an increased incidence of
oesophageal cancer.

Barium Swallow showing a stricture indicating

oesophageal cancer

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[ Q: 50 ] MRCPass - Gastroenterology

A 40 year old man has recurrent
episodes of bloody diarrhea and lower
abdominal cramping. Histologic evaluation of
a biopsy from flexible sigmoidoscopy reveals
acute inflammation without architectural
distortion consistent with ulcerative colitis.

Which of the following conditions is associated
with the condition?

1- Gallstones

2- Sclerosing cholangitis

3- Erythema nodosum

4- Renal calculi

5- Vitamin Bi 2 deficiency

Answer & Comments

Answer: 2- Sclerosing cholangitis

75% of patients with primary sclerosing
cholangitis have inflammatory bowel disease,
especially ulcerative colitis.

Primary sclerosing cholangitis (PSC) is a
chronic cholestatic liver disease of unknown
etiology. In the absence of underlying bile
duct abnormalities, a generalized beading and
stenosis of the intrahepatic and extrahepatic
biliary tree characterize PSC. PSC is usually
progressive, leading to cirrhosis, portal
hypertension, and liver failure.

Typically, a cholestatic jaundice picture is seen
with the liver function tests.

[ Q: 51 ] MRCPass - Gastroenterology

A 40 year old woman presents with
abdominal pain and watery diarrhoea. She has
joint pains and also has been investigated for
infertility. She was given a proton pump
inhibitor by her GP and this helped to relieve
some of her symptoms.

Investigations show :

Haemoglobin 13 g/dl

Calcium 2.90 mmol/I

Albumin 40 g/l

Phosphate 0.8 mmol/l

CRP 10 mg/I

Endoscopy - multiple small duodenal ulcers
H. pylori test - negative
What is the likely diagnosis?

1- NSAID induced duodenal ulceration

2- Multiple endocrine neoplasia

3- Small Bowel Lymphoma

4- Coeliac disease

5- Addison's disease

Answer & Comments

Answer: 2- Multiple endocrine neoplasia

MEN 1 would fit the clinical diagnosis. The
abdominal symptoms are likely to be due to
gastrinoma and hypercalcaemia due to
parathyroid adenoma. Infertility could be
explained by a prolactinoma.

[ Q: 52 ] MRCPass - Gastroenterology

A 65 year man who is on warfarin for
atrial fibrillation is complaining of worsening
breathlessness over the last 2 months. On
examination, he has an irregular heart beat,
blood pressure of 110 / 60 mmHg and he
looked pale.

There was no evidence of organomegaly.
Investigations show:

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Haemoglobin 8.5 g/dL
MCV 70 fL
PLT 160 x 10 9 /L

His upper gastrointestinal tract endoscopy and
colonoscopy were normal.

pain on swallowing and has regurgitation of
food Swallowed several hours earlier. He has
not lost weight. Barium Swallow demonstrates
proximal dilatation of the oesophagus and
failure of relaxation of the lower oesophageal
sphincter.

What is the next best investigation?

1- Barium enema

2- Small bowel enema

3- Capsule endoscopy

4- Mesenteric angiography

5- CT abdomen

Answer & Comments

Answer: 3- Capsule endoscopy

There is microcytic anaemia. In this case, there
is still a possibility of angiodysplasia involving
the small bowel which may not have been
identified with OGD or colonoscopy. With
Capsule Endoscopy, a patient Swallows a small
pill which emits a radio frequency which is
picked up by a sensor that the patient wears
over several hours. Images are then
downloaded as a continuous movie . At
present, this technique is ideal for patients
with suspected Gl bleeding within the small
bowel.

[ Q: 53 ] MRCPass - Gastroenterology

A 50 year old man presents with a
history of intermittent, but slowly progressive
dysphagia for both solids and liquids. He has

Which treatment option is best in the long
term ?

1- Sengstaken Blakemore tube

2- Amyl nitrite

3- Oesophageal myotomy

4- Intrasphincteric botulinum toxin

5- Terlipressin

Answer & Comments

Answer: 3- Oesophageal myotomy

The diagnosis is achalasia of the cardia. This is
a functional obstruction at the low er
oesophageal sphincter caused by a failure of
relaxation. Heller's oesophageal myotomy is
the best treatment option, it can be done via
an abdominal incision or laparascopically.

[ Q: 54 ] MRCPass - Gastroenterology

A 35 year old woman presented with
a 5-month history of weight loss (half a stone),
anorexia and generalized pruritus. On
examination, she was jaundiced with

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numerous spider naevi, scratch marks, palmar
erythema and hepatosplenomegaly.

Investigations showed :

Haemoglobin: 9.5 g/dl

WCC: 7 x 10 9 /l

erythrocyte sedimentation rate: 140mm/h

serum albumin: 41 g/l

serum bilirubin: 34 pmol/l

alanine transaminase: 152 iu/l

aspartate transaminase: 164 iu/l

alkaline phosphatase: 83 iu/l

The prothrombin time was prolonged but urea
and electrolytes, calcium and phosphate
concentrations were normal.

In addition to the above findings, which one of
the following would make the diagnosis of
autoimmune hepatitis likely ?

1- HLADR2

2- HLADR6

3- Anti neutrophil cytoplasmic antibodies

4- Antimitochondrial antibodies

5- High IgG

Answer & Comments

Answer: 5- High IgG

Antinuclear antibodies ANA) of IgG class are
frequently strongly positive (e.g. to a titre of
1/10000) in autoimmune hepatitis. Antibodies
to LKM, dsDNA and to smooth muscle are also
good markers.

HLA-DR3 and DR4 antigen are associated with
autoimmune hepatitis.

ALT 75 (5-35) U/l
AST 70(1-31) U/l
ALP 350 (20-120) U/l
Bilirubin 70 (1-22) pmol/l
Albumin 38 (37-49) g/l
What is the likely diagnosis?

1- Primary biliary cirrhosis

2- Gallstones

3- Cholangiocarcinoma

4- Intrahepatic cholestasis of pregnancy

5- Viral hepatitis

Answer & Comments

Answer: 4- Intrahepatic cholestasis of
pregnancy

Intrahepatic cholestasis of pregnancy usually
presents during the third trimester, at a mean
of 30 weeks of gestation. The characteristic
symptom is itching (pruritus gravidarum),
which involves the trunk, extremities, palms,
and soles. The itching may be severe, and it is
often worse at night.

Jaundice develops in 20 to 60 percent of
women one to four weeks after the onset of
itching. The features of obstructive jaundice,
including pale stools and dark urine, may be
present, but patients do not have
constitutional symptoms. Intrahepatic
cholestasis is associated with an increased risk
of prematurity and stillbirth. Women with
intrahepatic cholestasis should be treated at
centers capable of caring for premature
infants. Cholestyramine, given in divided
doses totaling 10 to 12 g per day, may help
relieve pruritus.

^ [ Q: 55 ] MRCPass - Gastroenterology

* A 78 vear nld laHv i<; 34 wppk^

|_ s

[ Q: 56 ] MRCPass - Gastroenterology

/ \ Z—m W V ^ Cl 1 1 1 Cl ^ V 1 O 1 V V ^ ^ lx o

pregnant. This is her second pregnancy, the

A 35 year old secretary has noticed

first pregnancy was uneventful. She has
pruritus and on examination, was mildly
jaundiced. Liver function tests showed:

jaundice over the last several months. Around
this time, she has also noticed itchiness all
over her body. On examination, she has

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xanthelasma around her eyes and palpable
hepatomegaly.

Her blood tests show Bilirubin 110 pmol/l (1-
22), AST of 240 U/l (1-30) and ALP of 650 U/l
(5-35 U/l). AMA is positive.

If she has primary biliary cirrhosis, what is the
liver biopsy likely to show ?

1- Granulomatous changes of hepatocytes

2- Fatty changes of the liver parenchyma

3- Piecemeal necrosis and fibrosis around
portal veins

4- Collagen layering around bile ducts

5- White cell infiltrates causing biliary duct
destruction

Answer & Comments

Answer: 5- White cell infiltrates causing biliary
duct destruction

^ [ Q: 57 ] MRCPass - Gastroenterology

n -

* A 45 year old man presents with an
episode of severe haematemesis following a
heavy meal. He also has had a day's history of
malena. On examination, he has swelling
around the gastric region and abdomen.

What is the most likely diagnosis?

1- Gastric ulcer

2- Mallory weiss tear

3- Oesophageal varices

4- Oesophageal web

5- Pancreatic carcinoma

Answer & Comments

Answer: 3- Oesophageal varices

Post prandial swelling suggests oesophageal
varices (portal hypertension).

Inflammatory changes with biliary destruction
are suggestive of primary biliary cirrhosis.
Granulomatous changes would suggest
sarcoidosis or Wegener's granulomatosis.
Piecemeal necrosis and fibrosis suggests
chronic hepatitis.

Primary biliary cirrhosis can present with
jaundice, pruritus, xanthelasma and signs of
chronic liver disease.

Antibodies (Anti Mitochondrial Antibody) and
liver biopsy are helpful to distinguish between
the PBC, autoimmune hepatitis and primary
sclerosing cholangitis.

Postprandial hyperemia leads to an increase in
portal pressure that may contribute to
esophageal variceal rupture.

[ Q: 58 ] MRCPass - Gastroenterology

A 30 year old lady presents with
bilateral swelling and discomfort around her
face. This caused her pain when she is chew
ing. It started 2 days ago and she also has mild
fever and headache. She mentioned she had
been in contact with someone with a similar
illness 2 weeks ago. On examination, she has
bilateral parotid enlargement which are
tender.

Which of the following is a likely cause?

1- Myotonic dystrophy

2- Marfan's syndrome

3- Myeloma

4- Carotid artery stenosis

5- Mumps

Histology showing destruction of bile ductules
within the triads of the liver in PBC

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Answer & Comments

Answer: 5- Mumps

There are many causes of parotid swellings.
Viruses include mumps, coxsackie A virus,
parainfluenzae virus, CMV and varicella zoster
virus. Hypothyroidism can do so, but not
hypoparathyroidism.

The incubation period for mumps is usually 18
to 21 days. Mumps is caused by a
paramyxovirus, and are spread from person to
person by saliva droplets or direct contact
with articles that have been contaminated
with infected saliva. The parotid glands (the
salivary glands between the ear and the jaw)
are usually involved. Unvaccinated children
between the ages of 2 and 12 are most
commonly infected, but the infection can
occur in other age groups. Orchitis (swelling of
the testes) occurs in 10-20% of infected males,
but sterility only rarely ensues; a viral
meningitis occurs in about 5% of those
infected.

Parotid Swelling

[ Q: 59 ] MRCPass - Gastroenterology

A 50 year old man has a history of
Crohn's colitis. He has relapses despite being
on mesalazine. The last relapse, treated high
doses of steroids, was complicated by
gastrointestinal bleeding.

Investigations show :

Haemoglobin 11.8 g/L

MCV 75 fL
MCH 25 pg (28-32)

White cell count 9 x 10 9 /L

Platelets 350 x 10 9 /L

Serum total protein 72 g/L (61-76)

Serum albumin 28 g/L (37-49)

Serum CRP 45 mg/L (<10)

Abdo X ray is normal

Which of the following is the most appropriate
management?

1- A trial of oral metronidazole

2- Treatment with azathioprine

3- Treatment withoral budesonide

4- Ileostomy

5- Total colectomy

Answer & Comments

Answer: 2- Treatment with azathioprine

This patient has not responded to first line
therapy. The next step is a trial of
azathioprine, which used as a steroid sparing
agent. This particularly so when theere are
side effects from previous steroid treatment.

Metronidazole is rarely effective in the
treatment of active Crohn's colitis. Given that
Crohn's disease can recur following surgery,
surgery should not be undertaken without a
trial of second line therapies such as
azathioprine first.

[ Q: 60 ] MRCPass - Gastroenterology

A 35 year old lady has developed
worsening pruritus and jaundice over the past
year. Investigations revealed a positive
antimitochondrial antibody and a liver biopsy
confirmed the diagnosis of primary biliary
cirrhosis.

Which of the following is associated with the
condition?

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1- Raised IgA

2- Male

3- Xanthelasma

4- Anti gliadin antibody

5- Diverticular disease

Answer & Comments

Answer: 3- Xanthelasma

Primary biliary cirrhosis is more common in
females and is usually associated with raised
IgM levels. Xanthelasma are present due to
cholestasis. Connective tissue disorders such
as Sjogren's syndrome are associated. A
positive antimitochondrial antibody and liver
biopsy are best ways to confirm the diagnosis.

Xanthelasma

[ Q: 61 ] MRCPass - Gastroenterology

A 50 year old man presents with
lower back pains and lethargy. Investigations
subsequently confirmed obstructive
nephropathy and retroperitoneal fibrosis. His
medication is reviewed on the ward round.

Which medication is well known to cause
retroperitoneal fibrosis ?

1- Isoniazid

2- Rifampicin

3- Cyclosporin

4- Aspirin

5- Methysergide

Answer & Comments

Answer: 5- Methysergide

Retroperitoneal fibrosis is a disease featuring
the proliferation of fibrous tissue in the
retroperitoneum, the compartment of the
body containing the kidneys, aorta, renal tract
and various other structures. It may present
with low er back pain, renal failure,
hypertension, deep vein thrombosis and other
obstructive symptoms.

Its may have an autoimmune etiology. One-
third of the cases are secondary to
malignancy, medication (methysergide,
hydralazine, beta blockers), aortic aneurysm
or certain infections.

Methyldopa, methysergide, amphetamines,
beta blockers, cocaine and LSD are drugs
which cause retroperitoneal fibrosis.
Azathioprine is used to treat the condition.

[ Q: 62 ] MRCPass - Gastroenterology

A 35 year old man has HIV infection.
Recently his CD4 count has dropped to 250
from 600 and viral load has dropped from
10,000 copies to 2000 copies /ml. He has now
developed diarrhoea.

Which one of the following is likely to cause
diarrhoea in a HIV positive patient?

1- Staph aureus

2- Strep pyogenes

3- Cryptosporidium

4- Mycobacterium tuberculosis

5- Neisseria meningitidis

Answer & Comments

Answer: 3- Cryptosporidium

Common organisms such as entamoeba,
salmonella, giarda, Campylobacter,
Cryptosporidium, cyclospora, mycobacterium
and also viral causes can cause diarrhoea in
HIV positive patients.

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[ Q: 63 ] MRCPass - Gastroenterology

A 70 year old man is admitted with
pruritus, lethargy and jaundice. He has not
drunk any alcohol for five years.

One month ago, he completed a course of
CoAmoxiclav which was prescribed by his GP.
He also takes diclofenac for osteoarthritis.

Investigations reveal:

Albumin 37 g/L

Bilirubin 180 umol/L

AST 220 iu/L

Alkaline Phosphatase 210 iu/l

Abdominal ultrasound reveals gallsones
without biliary duct dilatation.

Whot is the likely cause of his jaundice?

1- Hepatitis C infection

2- Diclofenac

3- Cholangiocarcinoma

4- Co-Amoxiclav

5- Alcoholic cirrhosis

Answer & Comments

Answer: 4- Co-Amoxiclav

5- Spironolactone

Answer & Comments

Answer: 4- Terlipressin

Octreotide and terlipressin are used to
prevent secondary variceal bleeding.
Octreotide is a somatostatin analogue.

[ Q: 65 ] MRCPass - Gastroenterology

A 40 year old man presents with
slurring of his speech and unsteadiness.

He has a coarse tremor in his hands and
ataxic, shuffling gait on examination.

His blood tests show normal renal function.

AST is 250 (1-30) U/l, ALP is 350 (1-250) U/l
and Bilirubin is 45 (1-22).

Which is the best investigation to confirm a
diagnosis?

1- Hepatitis screen

2- Serum Cu and caeruloplasmin

3- MRI of brain

4- Serum ferritin

5- IT 15 gene test for Huntington's

Co amoxiclav (Augmentin) can cause
hepatitic/cholestatic drug induced jaundice. A
4 week delay in symptoms signs is not
uncommon.

^ [ Q: 64 ] MRCPass - Gastroenterology

* A 50 year old alcoholic patient
presents with upper Gl bleeding. Urgent
endoscopy confirms oesophageal varices.

Which of the following can be used to prevent
secondary variceal haemorrhage?

1- Thyroxine

2- Cefotaxime

3- Frusemide

4- Terlipressin

Answer & Comments

Answer: 2- Serum Cu and caeruloplasmin

Wilson's disease can present with early
Parkinsons, psychiatric symptoms and
dysarthria. It also causes abnormal liver
function. It is an autosomal recessive
condition. Serum copper and caeruloplasmin
are low . Urinary copper excretion is raised.

[ Q: 66 ] MRCPass - Gastroenterology

A 30 year old Irish lady has a 15 year
history of non-specific abdominal pains and
diarrhoea. The symptoms are worse with
certain foods. Her AXR is unremarkable.

Which of the following tests is most likely to
confirm the diagnosis?

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1- Amylase

2- Anti gliaden and anti endomysial antibodies

3- Smooth muscle antibodies

4- Ferritin

5- B12 levels

Answer & Comments

Answer: 2- Anti gliaden and anti endomysial
antibodies

Coeliac disease (gluten sensitive enteropathy)
is relatively common in Ireland. The patient's
history suggests gluten sensitivity. Gluten is
found in wheat, rye and barley.

[ Q: 68 ] MRCPass - Gastroenterology

A 50 year old man has returned from
India recently and presents with diarrhoea.

Which of the following is the commonest
cause of traveller's diarrhoea?

1- Giardia Lamblia

2- Yersinia enterocolitica

3- E. Coli

4- Shigella Flexneri

5- Entamoeba Histolytica

Answer & Comments

Answer: 3- E. Coli

[ Q: 67 ] MRCPass - Gastroenterology

A 35 year old man has who has a
history of heavy alcohol intake presents with
hematemesis and melena. On admission, he
was in a preshock state with severe anemia
and was resuscitated with blood and fresh
frozen plasma. Endoscopic examination
identified bleeding from the varices in the
second portion of the duodenum.

Which one of the following drugs can be used
for treatment?

1- Octreotide

2- Vitamin C

3- Simvastatin

4- Carbimazole

E. Coli is the commonest cause of travellers
diarrhoea. It is usually a self limiting condition.

[ Q: 69 ] MRCPass - Gastroenterology

A 60 year old man presents with a 4
month history of dysphagia and weight loss. A
diagnosis of achalasia is made.

Which of the following is the best way to
provide symptomatic relief?

1- Surgical cardiomyotomy

2- Propanolol

3- Isosorbide mononitrate

4- Gaviscon

5- Magnesium trisilicate

5- Bromocriptine

Answer & Comments

Answer: 1- Octreotide

Somatostatin and its derivative, octreotide,
are often used for emergency treatment of
bleeding oesophageal varices in patients with
cirrhosis of the liver. It is given intravenously.

Answer & Comments

Answer: 1- Surgical cardiomyotomy

Cardiomyotomy entails surgical division of the
lower oesophageal sphincter. Mortality rates
of less than 1% and success rates of over 85%
have been recorded. There is However a high
incidence (up to 10%) of oesophageal reflux
post-operatively progressing in a number of
cases to peptic stricture. For achalasia,
nitrates and hydralazine can help in short
term.

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[ Q: 70 ] MRCPass - Gastroenterology

A 35 year old man presents with
jaundice. He has been on a drug which was
prescribed by his GP for several weeks. His
blood tests show a bilirubin of 34pmol/l, ALP
of 450 U/land AST 50 U/l.

Which one of the following drugs is likely to
co use cholestatic jaundice?

1- Chlorpromazine

2- Paracetamol

3- Ibuprofen

4- Allopurinol

5- Colchicine

Answer & Comments

Answer: 1- Chlorpromazine

Chlorpromazine, tricyclic antidepressants,
azathioprine, augmentin and erythromycin
cause cholestatic jaundice and also associated
hepatitis.

the majority of binge-drinking alcoholics and is
a common cause of anemia. Inadequate
dietary intake, intestinal malabsorption, and
impaired folate storage in the liver all
contribute to folate deficiency.

^ [ Q: 72 ] MRCPass - Gastroenterology

fi -

# A 20 year old patient has recently
returned from travelling in South Africa, and is
unwell with diarrhoea. She had a 2-week
history of profuse loose brow n stools,
lethargy, weakness, nausea and abdominal
discomfort. The diarrhoea had initially settled
with loperamide, but then recurred again.

A faecal specimen was collected for
microscopy and culture, and it subsequently
grew Giardia lamblia.

Whot medication should be used for
treatment?

1- Amoxycillin

2- Albendazole

3- Metronidazole

[ Q: 71 ] MRCPass - Gastroenterology

A 40 year old woman has drunk 50
units a week of alcohol for 20 years.

During investigations, she has :

Haemoglobin 10.2 g/dL, MCV 110 fL (80-96),
white cell count 2.1 x 10 9 /L (4-11), platelet
count 75 x 10 9 /L (150-400).

What might explain these results?

1- Liver cirrhosis

2- Folic acid deficiency

3- Hepatitis C infection

4- Iron deficiency

5- Multiple myeloma

Answer & Comments

Answer: 2- Folic acid deficiency

The haematological picture is that of B12 or
folate deficiency. Folate deficiency occurs in

4- Erythromycin

5- Gentamicin

Answer & Comments

Answer: 3- Metronidazole

Giardia lamblia infection can present with
abdominal pains and diarrhoea or
steatorrhoea. Metronidazole or tinidazole are
first line treatments. It does not cause
dysentery (cholera or amoebiasis do).
Duodenal aspirate biopsy can confirm the
diagnosis. Villous atrophy is associated.

[ Q: 73 ] MRCPass - Gastroenterology

A 60 year old woman presents with a
12 month history of chest pain, dysphagia
when consuming both solids and liquids. She
smokes 15 cigarettes per day and drinks 12
units of alcohol per week. Clinical examination
was normal.

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What is the likely diagnosis?

1- Oesophagitis

2- Oesophageal web

3- Pharyngeal pouch

4- Achalasia

5- Oesophageal carcinoma

Answer & Comments

Answer: 4- Achalasia

A longstanding history of dysphagia with both
solids & liquids suggests a functional rather
than mechanical cause. Achalasia, in which
there failure of oesophageal peristalsis and
relaxation of lower oesophageal sphincter fits
the clinical picture best.

^ [ Q: 75 ] MRCPass - Gastroenterology

# A 50 year old man has 5 year history
of bloody diarrhoea mixed with mucus. He
had lost 2 stones in weight over this time.
Flexible sigmoidoscopy showed loss of
vascular appearance, erythema, and
superficial ulceration consistent with
ulcerative colitis.

Which one of the following features is
associated with the condition?

1- Rheumatoid arthritis

2- Acromegaly

3- Osteomalacia

4- Megaloblastic anaemia

5- Episcleritis

[ Q: 74 ] MRCPass - Gastroenterology

A 55 year old man has a long history
of alcohol use. On the average he drinks two
bottles of wine a day. He presents with
tremors, hallucinations and has signs of
chronic liver disease as well as ascites. The
senior house officer assesses the status of
chronic liver disease with the Child Pugh
Classification.

Answer & Comments

Answer: 5- Episcleritis

Megaloblastic anaemia occurs in Crohn's as
B12 is absorbed in the ileum.

Ulcerative colitis is also associated with:

aphthous ulcers of the mouth

Iritis/Uveitis and episcleritis

Which of the following is one of the criteria
used to assess severity?

1- Haemoglobin

2- AST

3- Sodium

4- Creatinine

5- Prothrombin time

Answer & Comments

Answer: 5- Prothrombin time

Child Pugh classification includes bilirubin
level, prothrombin tine, encephalopathy
scores, ascites and albumin. AST is not used to
assess severity of liver disease.

seronegative arthritis, ankylosing spondylitis,
sacroilitis

erythema nodosum, pyoderma gangrenosum

Primary sclerosing cholangitis,

cholangiocarcinoma

Episcleritis

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[ Q: 76 ] MRCPass - Gastroenterology

Answer & Comments

A 60 year old man is admitted as an

Answer: 4- Achlorhvdria

emergency with severe abdominal pain. He
smokes 30 cigarettes a day and takes
approximately 30 units of alcohol per week
but admits to exceeding this amount
occasionally. He also complains of sudden
onset poor vision. Ophthalmoscopy shows
multiple micro infarcts (cotton wool spots).

What investigation should be considered next?

1- Carotid dopplers

2- CT scan abdomen

3- E.R.C.P.

4- Upper Gl endoscopy

5- Colonoscopy

Answer & Comments

Answer: 2- CT scan abdomen

Ischaemic retinopathy, which causes retinal
oedema and micro infarcts, is a complication
of acute pancreatitis. CT scan of the abdomen
will be useful in confirming diagnosis and
assessing for the presence of a pancreatic
abscess/pseudocyst.

VIPomas in adults are usually neuroendocrine
islet cell tumors of the pancreas that produce
high amounts of VIP. Other secreted
hormones may include secreted gastrin and
pancreatic polypeptide.

Achlorhydria (lack of acidity from the
stomach) is classically associated with VIPoma.
It can be diagnosed by measuring acid output
from nasogastric contents (NG tube). Features
of VIP syndrome include watery diarrhea,
hypochlorhydria, hyperglycemia,

hypercalcemia and flushing. Migratory
erythema associated with glucagonoma.

[ Q: 78 ] MRCPass - Gastroenterology

A 45 year old woman presents with
jaundice and several weeks before had
pruritus all over her body. Her only past
medical history is Hashimoto's thyroiditis. On
examination, she has jaundice, xanthelasmata
and hepatomegaly.

Which of the following is the most likely cause
of the jaundice?

[ Q: 77 ] MRCPass - Gastroenterology

A 43 year male presents with weight
loss and watery diarrhoea for several weeks.
Investigations reveal hypokalaemia.

Which of the following would support a
diagnosis of a VIPoma?

1- Hypoglycaemia

2- Raised Insulin levels

1- Cholecystitis

2- Primary biliary cirrhosis

3- Systemic lupus erythematosus

4- Hepatitis C

5- Cholangiocarcinoma

Answer & Comments

Answer: 2- Primary biliary cirrhosis

3- Pellagra

4- Achlorhydria

5- Erythema nodosum

Primary biliary cirrhosis commonly affects
women at the age of 45-60. Pruritus often
precedes jaundice.

Hashimoto's thyroiditis as well as other
autoimmune conditions are associated.
Xanthelasmata are often present in patients
with primary biliary cirrhosis.

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[ Q: 79 ] MRCPass - Gastroenterology

A 35 year old woman has abdominal
pain, jaundice and worsening ascites. She
drinks 20 units of alcohol each week, and
takes the oral contraceptive pill.

Which of the following findings would make a
diagnosis of Budd Chiari syndrome likely?

1- Encephalopathy

2- Tender hepatomegaly

3- Ascites fluid protein of 42 g/L

4- Alanine aminotransferase of 150 U/L

5- Ankle oedema

Answer & Comments

Answer: 2- Tender hepatomegaly

Budd-Chiari syndrome is an uncommon
condition induced by thrombotic or
nonthrombotic obstruction to hepatic venous
outflow . The classic triad of abdominal pain,
ascites, and hepatomegaly is observed in the
vast majority of patients but is nonspecific.
Tender hepatomegaly on examination is one
of the hallmark signs.

Proton pump inhibitors such as omeprazole,
lansoprazole and pantoprazole are more
effective than H2 receptor blockers such as
ranitidine, cimetidine or nizatidine. Healing in
oesophagitis is beter with a PPI although all of
the options can reduce symptoms due to acid
reflux.

[ Q: 81 ] MRCPass - Gastroenterology

/ -

# A 65 year old man presents with
dysphagia of solids for the past three months.
There is a history of 10 kg weight loss in 4
months following loss of appetite. He has had
symptoms of indigestion and heartburn for 10
years. He regularly takes Gaviscon and milk of
magnesia. He is a heavy smoker. He
undergoes endoscopy, which reveals a small
tumour at the lower part of the oesophagus.

What is the likely aetiological cause?

1- Barrett's oesophagus

2- Helicobacter pylori

3- Oesophageal pouch

4- Family history

5- Colonic carcinoma metastases

[ Q: 80 ] MRCPass - Gastroenterology

A 50 year old lady complains of
epigastric burning pains due to stress. She
finally undergoes an OGD which shows gastro-
oesophageal reflux.

Which medication is the most effective for her
condition?

1- Nizatidine

2- Bismuth

3- Gaviscon

Answer & Comments

Answer: 1- Barrett's oesophagus

The history is suggestive of gastro
oesophageal reflux past 10 years. There may
be dysplasia of the oesophageal mucosa
known as Barrett's oesophagus. In Barrett's
oesophagus the stratified squamous
epithelium that normally lines the distal
oesophagus is replaced by an abnormal
columnar epithelium that has intestinal
features.

4- Magnesium trisilicate

5- Pantoprazole

Answer & Comments

Answer: 5- Pantoprazole

Modern data indicate that patients with
Barrett's oesophagus develop oesophageal
adenocarcinomas at the rate of 0.5% per year,
a rate that is more than 30-fold higher than
that of the general population.

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[ Q: 82 ] MRCPass - Gastroenterology

A 60 year old man has been referred
by his GP for investigatio of hepatomegaly. His
past medical history includes type II diabetes
and longstanding arthralgia.

Investigations show :

Albumin 28 g/L

Total bilirubin 45 umol/L

Alkaline Phosphatase 170 U/L

ALT 180 U/L

gamma glutamyl transferase 160 U/L
Ferritin 1200 microg/L (15-400)

What is the diagnosis?

1- Primary biliary cirrhosis

2- Non alcoholic steatohepatitis

3- Diabetes mellitus

4- Wilson's disease

5- Haemochromatosis

Answer & Comments

Answer: 5- Haemochromatosis

The diagnosis of haemochromatosis is based
on clinical features of the disease; these
features include diffuse hyperpigmentation,
non migratory polyarthritis, chondrocalcinosis,
hepatomegaly, and diabetes mellitus. There is
also deranged liver function tests and
significantly high ferritin in this case, pointing
tow ards the diagnosis.

1- Propanolol

2- Nasogastric tube

3- Intravenous pantoprazole

4- Terlipressin

5- Lactulose

Answer & Comments

Answer: 4- Terlipressin

The patient has clinical evidence of cirrhosis of
the liver and likely oesophageal varices.

Octreotide and terlipressin are widely used in
acute variceal hemorrhage to reduce the
bleeding rate. They act by causing mesenteric
arterial vasoconstriction, thus reducing portal
venous flow and portal pressure.

[ Q: 84 ] MRCPass - Gastroenterology

A 60 year man presents with
malaise, weight loss, diarrhoea and pain in the
joints. He is pigmented, has clubbing and
lymphadenopathy. He has ascites and
ophthalmoplegia. Investigations show that he
is anaemic. ECG shows a right bundle branch
block and paracentesis abdominis reveals
chylous ascites.

What is the likely diagnosis?

1- Wilson's disease

2- Tropical sprue

3- Whipple's disease

4- Coeliac disease

[ Q: 83 ] MRCPass - Gastroenterology

A 45 year old man presents with
haematemesis and melaena. He gives a
history of drinking 20 units of alcohol a day for
more than 15 years. On examination he has
spider naevi, Dupuytren's contracture,
jaundice and ascites.

Whilst awaiting endoscopy the initial
management of this patient should be:

5- Crohn's disease

Answer & Comments

Answer: 3- Whipple's disease

The diagnosis is Whipple's disease. Histology
of small bowel biopsy will show multiple
macrophages in the lamina propria and the
presence of rod shaped bacteria (Trophyrema
Whippelli) both within and outside the
abnormal macrophages.

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PAS stained macrophages in duodenal biopsy

(purple)

[ Q: 85 ] MRCPass - Gastroenterology

A 30 year old man presents with
longstanding epigastric pains. An abdominal
CT was organised and this showed dilated
pancreatic ducts.

The secretin test is positive.

The patient has a HB of 13 g/dl, MCV of 105 fl
and platelet count of 350 x 10 9 /l .

The high MCV is most likely due to:

1- Folic acid deficiency

2- B12 deficiency

3- Myelodysplastic syndrome

4- Reticulocytosis

5- Paroxysmal nocturnal haemoglobinuria

Answer & Comments

Answer: 2- B12 deficiency

In chronic pancreatitis, trypsin secretion is
reduced. Trypsin is required in the processing
of dietary B12 which enables absorption and
hence B12 deficiency is the most likely in this
case.

[ Q: 86 ] MRCPass - Gastroenterology
A 40 year old heavy alcoholic

presents unwell with difficulty walking and
confusion.

On examination, he has signs of chronic liver
disease, hepatomegaly and ascitis.

Blood tests confirm deranged liver function
including AST and GGT.

Which one of the following is the most
important monifestotion of acute hepatic
failure ?

1- Prolonged prothrombin time

2- Hepatic encephalopathy

3- Elevated ALT and AST

4- Jaundice

5- Ascites

Answer & Comments

Answer: 2- Hepatic encephalopathy

Hepatic encephalopathy is the cardinal
manifestation of acute hepatic failure.

It is characterized by various neurologic
symptoms including changes in reflexes,
changes in consciousness, and behavior
changes that can range from mild to severe.

The exact cause is unknown, but one
substance believed to be particularly toxic to
the central nervous system is ammonia which
is normally detoxified by the liver.

[ Q: 87 ] MRCPass - Gastroenterology

m A 20 year girl is commenced on
nasogastric feeding due severe anorexia
nervosa. She becomes acutely confused after
a week.

Which one of the following investigations
should be reguested?

1- Troponins

2- Serum Calcium

3- Serum Bicarbonate

4- Serum Magnesium

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5- Serum Potassium

* serum AST >250 IU/L

Answer & Comments

Answer: 4- Serum Magnesium

Refeeding syndrome of hypophosphataemia,
hypomagnesaemia, hypocalcaemia and fluid
retention is seen in severely malnourished
patients when they are started on enteral or
parenteral nuitrition. In particular,
hypomagnesaemia can cause cardiac rhythm
problems and confusion.

* serum LDH >350 IU/L
At 48 hours

* Calcium (serum calcium < 2.0 mmol/L (< 8.0
mg/dL)

* Hematocrit fall > 10%

* Oxygen (hypoxemia P02 < 60 mmHg)

* Urea increased by 1.8 or more mmol/L (5 or
more mg/dL) after IV fluid hydration

[ Q: 88 ] MRCPass - Gastroenterology

A 45 year old man presents with
epigastric pain and vomiting. He had pain
located at the upper abdomen for the last 8
hours prior to admission. The patient also
complained of nausea and two episodes of
vomiting. He has an amylase of 500 (60-180)
U/l. Ultrasound of the abdomen showed a
pancreas with enhanced echogenicity.

Which of the following is o poor prognostic
indicator?

1- White cell count of 10 x 10 9 /L

2- Urea of 7 mmol/l

3- Glucose of 8 mmol/l

4- ALT of 350 U/l

5- Calcium of 2.8 mmol/l

Answer & Comments

Answer: 4- ALT of 350 U/l

Poor prognostic indicators in acute
pancreatitis can be assessed with the Ranson
Criteria or APACHE scores.

Ranson's criteria:

At admission

* age in years > 55 years

* white blood cell count > 16000 cells/mm 3

* blood glucose > 10 mmol/L (> 200 mg/dL)

* Base deficit (negative base excess) > 4
mEq/L

* Sequestration of fluids > 6 L

[ Q: 89 ] MRCPass - Gastroenterology

A 55 year old chronic alcoholic is
found on the street with a low conscious level.
His GCS is 3/15 on arrival in casualty. On
examination, his BP is 110/65 and he is
jaundiced. There is marked ascites and he has
7 spider naevi.

ECG shows atrial fibrillation with a ventricular
rate of 120.

Which is the most practical test to elucidate
why he is unconscious?

1- EEG

2- Ultrasound of abdomen

3- BM stick

4- Phenytoin and carbamazepine levels

5- Paracetamol and salicylate levels

Answer & Comments

Answer: 3- BM stick

In a patient with liver disease, it is important
to exclude hypoglycaemia as a cause of
unconsciousness. Following confirming that
baseline observations and BM is normal, the
next best step is to perform a CT of his head to

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exclude a central neurological cause of
decreased conscious level.

[ Q: 90 ] MRCPass - Gastroenterology

A 28 year old woman has symptoms
of lethary, bloody diarrhoea and a previous
history of DVT in the leg. On examination, the
left eye was inflamed and multiple mouth
ulcers were noted. Colonoscopy was
organised and this confirmed colitis. She also
has vulval ulcers.

What is the likely diagnosis?

1- Homocystinuria

2- Erythema nodosum

3- Ulcerative colitis

4- Behcet's disease

5- Crohn's disease

Answer & Comments

Answer: 4- Behcet's disease

Recurrent oral ulceration is the commonest
manifestation and the presenting feature in
Behcet's disease. The commonest second
systems involved are the genital mucosae and
eyes. Vasculitis, pustules and subcutaneous
nodules also occur. Vascular thrombosis
occurs in about 10% of patients.

[ Q: 91 ] MRCPass - Gastroenterology

A 65 year man presents with a 6 day
history of lower abdominal pains and
diarrhoea. He has had several courses of
antibiotics for recurrent chest infections over
the past month. On examination he has a
temperature of 38.2°C, a blood pressure of
100/70 mmHg and a distended, tender
abdomen.

Which of the following is the most appropriate
investigation?

1- Plain abdominal and erect chest X ray

2- Flexible sigmoidoscopy

3- Stool PCR

4- Sputum culture

5- Ultrasound scan of abdomen

Answer & Comments

Answer: 1- Plain abdominal and erect chest X
ray

The diagnosis is pseudomembranous colitis
due Clostridium Difficile infection. The patient
was predisposed due to antibiotic usage. Plain
AXR is useful in diagnosing toxic dilatation and
erect CXR would exclude gas under the
diaphragm. Stool testing for Clostridial toxin
(CDT) would also be useful.

[ Q: 92 ] MRCPass - Gastroenterology

A 27 year old lady is referred for
investigation of abnormal liver function tests.
She has been taking several drugs to treat
tuberculosis for a long period of time.

Her albumin is 30 g/l, bilirubin 15 pmol/l, ALP
is 250 U/l and ALT is 300 U/l.

She has a liver biopsy which shows histological
evidence of liver necrosis eroding the portal
zone and extending into the liver lobule.

What is the likely diagnosis?

1- Hepatitis B infection

2- Hepatitis C infection

3- Primary biliary cirrhosis

4- Chronic active hepatitis

5- Autoimmune hepatitis

Answer & Comments

Answer: 4- Chronic active hepatitis

Inflammatory conditions (e.g Wilson's disease)
and drugs such as methyldopa and isoniazid
can precipitate chronic active hepatitis.

Autoimmune hepatitis is associated with anti¬
nuclear antibodies (70%), anti smooth muscle

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(30%) and liver specific antibodies (ASGP-R
asialoglycoprotein receptor; LKM liver kidney
microsomal antibodies).

[ Q: 93 ] MRCPass - Gastroenterology

A 60 year old woman has recently
been treated with amoxycillin for a tooth
abscess. Since then, she has developed
diarrhoea for up to 15 times a day. There is
blood in the stools.

Her Hb is 13 g/dl, WCC 13 x 10 9 /l, platelets
500 x 10 9 /L. Her CRP is 80 mg/I.

What is the likely infective organism?

1- Clostridium difficile

2- Cyclospora

3- Cryptospridium

4- Clostridium tetani

5- Campylobacter

Answer & Comments

Answer: 1- Clostridium difficile

In a patient who has recently had antibiotics,
Clostridium difficile is the most likely
infectdive organism.

5- Somatostatin

Answer & Comments

Answer: 5- Somatostatin

This patient has high grade liver cirrhosis
according to Childs Pugh classification.

Somatostatin acts to reduce portal pressures
and is as effective as endoscopic procedures
at controlling variceal bleeding in the acute
setting. Betablockers can be used as oral
prophylaxis oesophageal varices. IV
omeprazole can also be given.

^ [ Q: 95 ] MRCPass - Gastroenterology

<i -

# A 70 year old man presents with a six
month history of diarrhoea and pale stools. He
has lost 1 stone in weight over the past 6
months.

Investigations show :

Calcium 1.7 mmol/I
Phosphate 0.75 (0.8-8) pmol/l
Alkaline phosphatase 360 U/L (45-105)

What is the likely diagnosis?

1- Amoebiasis

Discontinuation of the offending antibiotic is
important (not always easy if an infection such
as a dental abscess persists). Metronidazole
and vancomycin given orally are equally
effective.

2- Pancreatic carcinoma

3- Whipple's disease

4- Crohn's disease

5- Small Intestinal bacterial overgrowth

[ Q: 94 ] MRCPass - Gastroenterology

A 48 year old man with Child's grade
C cirrhosis presents with haematemesis.

Which one of the following drugs ,
administered immediately intravenously ,
would be appropriate?

1- Propranolol

2- Sodium Nitroprusside

3- Isosorbide dinitrate

4- Pabrinex

Answer & Comments

Answer: 2- Pancreatic carcinoma

Pancreatic carcinoma is the most probable
diagnosis in view of his presenting symptoms
and age. The patient has osteomalacia
associated with malabsorption. Increased
alkaline phosphatase would not be expected
in Crohn's disease, Whipple's or bacterial
overgrowth.

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^ [ Q: 96 ] MRCPass - Gastroenterology

fj -

# An 18 year old arts student presents
with haematemesis. He has been out drinking
with his friends and drank about 15 pints of
beer. He vomited several times. The last time
he vomited he brought up several cupfuls of
blood.

What is the most likely cause of his
haematemesis?

1- Mallory-Weiss tear

2- Hyponatraemia

3- Oesophageal varices

4- Gastritis

5- Peptic ulcer

1- CT scan of abdomen

2- ERCP

3- Antimitochondrial antibody

4- HCV DNA levels

5- Liver biopsy

Answer & Comments

Answer: 5- Liver biopsy

Liver biopsy is useful to determine the severity
of the disease and for monitory progression
when treatment with ribavirin and interferon
is instigated. Cirrhosis develops in 20-25
percent of patients with chronic hepatitis C
after 10 years.

Answer & Comments

■ 7

[ Q: 98 ] MRCPass - Gastroenterology

Answer: 1- Mallorv-Weiss tear

L4J

A 30 year old woman presents in the

A Mallory-Weiss tear occurs at the gastro-
oesophageal junction when there is a sudden
increase in intra-abdominal pressure,
especially with recurrent vomiting.

second trimester of her first pregnancy with
jaundice. There are no other symptoms, and
her urine is not discoloured.

Blood tests show ALT 32 (5-35) U/l, AST 28 (1-
31) U/l, ALP 75 (20-120) U/l, GGT 31 (4-35)
U/l, Bilirubin 65 (1-22) pmol/l, Albumin 37 (37-
49) g/l.

The likely diagnosis is:

1- Dubin Johnson syndrome

2- Cholestasis of pregnancy

3- Gilbert's syndrome

4- Alcoholic liver cirrhosis

5- Primary biliary cirrhosis

Answer & Comments

[ Q: 97 ] MRCPass - Gastroenterology

A 40 year old man has worsening
jaundice and has deranged liver function tests
which have worsened over the last 3 months.
He has positive IgG to hepatitis C.

Which of the following investigations is most
useful for management of the condition?

Answer: 3- Gilbert's syndrome

This is unlikely to be intrahepatic cholestasis
of pregnancy because there is no elevation of
alkaline phosphatase and ALT/AST. The
condition is usually associated with intense
pruritus as well.

The isolated raised bilirubin makes a diagnosis
of Gilberts syndrome likely.

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Gilbert's syndrome is an autosomal recessive
condition characterized by intermittent
jaundice in the absence of hemolysis or
underlying liver disease. Unconjugated
hyperbilirubinemia in Gilbert syndrome has
long been recognized as due to underactivity
of the conjugating enzyme system bilirubin-
uridine diphosphate glucuronyl transferase
(bilirubin-UGT).

Jaundice in Gilbert syndrome may be
precipitated by dehydration, fasting,
menstrual periods, pregnancy, stress, such as
an intercurrent illness or vigorous exercise.

Dubin-Johnson syndrome is asymptomatic
mild jaundice due to impaired excretion of
bilirubin. In contrast to Gilbert's syndrome,
the hyperbilirubinemia is conjugated and bile
appears in the urine.

[ Q: 99 ] MRCPass - Gastroenterology

A 20 year old man is well but
jaundiced. His urine colour is normal. His liver
function tests show bilirubin 45 pmol/l, ALT 26
U/l, AST 25 U/l, GGT 40 U/l and ALP 80 U/l.

Ultrasound scan of abdomen shows normal
parenchymal texture of the liver.

Which diagnosis is most likely?

1- Dubin Johnson syndrome

2- Crigler Najjar syndrome

3- Gilbert's syndrome

4- Infectious mononucleosis

Crigler Najjar is a more severe form in which
the same enzyme is absent and there is
neonatal jaundice due to very high levels of
unconjugated hyperbilirubinaemia. In
contrast, Dubin Johnson syndrome leads to
high levels of conjugated bilirubin which will
lead to dark urine.

[Q: 100] MRCPass -
Gastroenterology

A 40 year old woman with epigastric pain
undergoes upper Gl endoscopy. A biopsy was
taken and it revealed a diagnosis of mucosal
associated lymphoid tissue.

Whot should be done initially?

1- Bilroth's operation

2- Proton pump inhibitor

3- H pylori eradication

4- Radiotherapy

5- Chemotherapy

Answer & Comments

Answer: 3- H pylori eradication

MALT lymphoma (or MALToma) is a relatively
rare form of non-Hodgkin's lymphoma.

70% of cases of MALT lymphoma affecting the
stomach are H pylori positive. Eradication of H
pylori is recommended. Chemotherapy
(chlorambucil), surgery and radiotherapy can
then be considered.

5- Haemochromatosis

Answer & Comments

Answer: 3- Gilbert's syndrome

Unconjugated hyperbilirubinemia in Gilbert
syndrome is due to underactivity of the
conjugating enzyme system bilirubin-uridine
diphosphate glucuronyl transferase (bilirubin-
UGT) which converts bilirubin to a conjugated,
water soluble form.

[Q: 101] MRCPass-
Gastroenterology

A 38 year old lady who is asymptomatic has an
ultrasound of her abdomen done privately. It
showed several gallstones and no biliary duct
dilatation. She has no other past medical
history.

What should be done?

1- Open cholecystectomy

2- Laparascopic cholecystectomy

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3- ERCP

4- Lithotripsy

5- Observation

Cholera and giardial diarrhoea are not
typically bloody. There is no history of
immunocompromise to suggest Cryptosporidia
infection.

Answer & Comments

Answer: 5- Observation

The natural history of asymptomatic
gallstones (GS) suggests that a large number
of affected individuals will remain
asymptomatic throughout life; only 1-4% per
year will develop symptoms or complications
of GS disease. Therefore, the natural history of
asymptomatic GSs is so benign that surgery is
generally not recommended and watchful
waiting is the best course of management.
Laparascopic cholecystectomy is

recommended for asymptomatic patients with
risks factors such as sickle cell disease and
diabetes.

A 23 year old man has recently travelled back
from the Middle East. He has previously been
well and there is no past medical history. He
has a 5 day history of bloody diarrhoea and
has acute abodminal pains.

On examination, he has a temperature of 38°C
and a tender lower abdomen.

What is the likely causative organism?

1- Cryptosporidium

2- Shigellosis

3- E coli

4- Giardiasis

5- Cholera

[Q: 102] MRCPass -
Gastroenterology

Shigellosis is spread by means of fecal-oral
transmission. Other modes of transmission
include ingestion of contaminated food or
water, contact with a contaminated inanimate
object, and sexual contact. Sudden onset of
severe abdominal cramping, high-grade fever,
emesis, anorexia, and large-volume watery
diarrhea are presenting features. Seizures,
delirium and haemolytic uraemic syndrome
are complications.

Cotrimoxazole and ampicillin are
recommended treatments.

A 45 year woman is admitted a single episode
of haematemesis after taking a tablet of
ibuprofen 6 hours previously.

On examination, she had a blood pressure of
120/75 mmHg (lying) and 95/60 mmHg
(standing). Her haemoglobin concentration is
7.5 g/dL.

What is the likely cause of the haemetemesis?

1- Duodenal ulcer

[Q: 103] MRCPass -
Gastroenterology

2- Oesophagitis

3- Mallory Weiss Tear

4- Gastric erosions

5- Gastric ulcer

Answer & Comments

Answer: 4- Gastric erosions

Answer & Comments

Answer: 2- Shigellosis

Bloody diarrhoea is more likely to be caused
by shigella.

The likely answ er is gastric erosions because
the bleeding occurred after only one dose of
Ibuprofen. There is no previous history of
dyspepsia or upper Gl bleeding. Nonsteroidal
anti-inflammatory drugs (NSAIDs), such as
aspirin, ibuprofen, and naproxen, can be
direct irritants and cause gastritis/erosions.

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Because of gravity, the irritants lie on the
greater curvature of the stomach, and
therefore, gastritis and ulcers are seen distally
on or near the greater curvature of the
stomach.

[Q: 104] MRCPass -
Gastroenterology

A 60 year old man presents with a 2-year
history of arthritis, fever, recurrent cough and
chest pain. He has been feeling very lethargic.
Recently he has developed diarrhoea
(steatorrhoea), abdominal pain and weight
loss.

On examination he is pigmented, there is
finger clubbing and lymphadenopathy. On
auscultation, a pan-systolic murmur is heard in
the cardiac apex.

Which of the following investigations would
confirm the clinical diagnosis?

1- Serum autoimmune screen

2- Abdominal X ray

3- Small bowel biopsy

4- Iron studies

5- Amylase

[Q: 105] MRCPass -
Gastroenterology

A 60 year old man has haematemesis and
melaena. Examination reveals jaundice,
confusion and a flapping tremor and ascites.
He has a pulse rate of 110 bpm and blood
pressure of 95/65 mmHg. An urgent
endoscopy reveals small oesophageal varices,
without evidence of bleeding but an oozing
portal hypertensive gastropathy.

Which of the following measures would be
appropriate treatment?

1- Endoscopic adrenaline injection

2- Intravenous vitamin K

3- Endoscopic banding

4- Oral propranolol

5- Endoscopic ethanolamine injection

Answer & Comments

Answer: 3- Small bowel biopsy

The patient has Whipple's disease, which may
be confirmed by small bowel biopsy. This will
show large, foamy PAS positive macrophages
in the lamina propria. Whipple's disease
affects mainly men aged 30 to 60. It is caused
by an infection with Trophyrema whippelii.

Symptoms of Whipple's disease include
diarrhoea, inflamed and painful joints, fever,
and skin darkening. Severe malabsorption
results in weight loss along with fatigue and
weakness caused by anaemia. Antibiotics such
as tetracycline, co-trimoxazole and penicillin
can be used for treatment (6-12 months).

Answer & Comments

Answer: 1- Endoscopic adrenaline injection

The endoscopy shows small varices with no
evidence of bleeding but there is diffuse
oozing of blood. Adrenaline injection (peri and
intralesional injection of 1:10,000 adrenaline
solution) will help to control the bleeding.
Correction of any coagulopathy with vitamin K
in this case will also be helpful.

[ft

A 65 year old man is admitted with a history of
sudden onset abdominal pain, followed by
watery diarrhoea and subsequent profuse
rectal bleeding. He has been a smoker for 40
years and had a myocardial infarction 5 years

[Q: 106] MRCPass
Gastroenterology

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ago. He has a family history of colon
carcinoma.

Whot is the likely diagnosis?

1- Sigmoid volvulus

2- Large bowel infarction

3- Rectal carcinoma

4- Ulcerative colitis

5- Crohn's disease

Answer & Comments

Answer: 2- Large bowel infarction

The history of pain, diarrhoea and bleeding
per rectum in a patient with vascular risk
factors suggests large bowel infarction.
Ischaemic bowel disease may be acute or
chronic. Most cases result from arterial
occlusion, usually of the superior mesenteric
artery. The small bowel is not commonly
involved.

A 60 year woman with a long history of
alcohol abuse has been on Phenytoin for
epilepsy. On examination, she has a palpable a
liver edge.

Her full blood count reveals:

Haemoglobin 11.0 g/dL
MCV116 fL

white cell count 2.3 x 10 9 /L

platelet count 95 x 10 9 /L

Whot is the likely explanation for these
results?

1- Aplastic anaemia

2- Vitamin C deficiency

3- Myeloma

4- Iron deficiency

5- Folate deficiency

[Q: 107] MRCPass -
Gastroenterology

Answer & Comments

Answer: 5- Folate deficiency

The patient has heavy alcohol intake and
phenytoin, hence is high risk for folate
deficiency causing the macrocytic anaemia.

[Q: 108] MRCPass -
Gastroenterology

A GP refers a 35 year old lady for recurrent
episodes of flushing. Over the past 10 years
she had these symptoms. She describes each
episode as starting with a freckled rash on her
thorax and limbs, pounding in her heart,
followed later by weakness, vomiting and
diarrhoea.

The patient had no other remarkable medical
history. She specifically denied having
pathologic fractures or peptic ulcer disease.
She was not taking prescription or
nonprescription medication; she had no
known allergies to medication or food.

Physical examination revealed a lady with
hundreds of reddish-brow n macules on his
arms, legs, and chest. The macules extended
onto the non-sun-exposed areas of her inner
forearms and urticated when stroked (positive
Darier sign).

Blood tests reveal eosinophilia, serum
tryptase, 43.3 ng/mL (reference range, <11.5
ng/mL); serum histamine, 1.2 ng/mL
(reference range, <1.0 ng/mL).

Which of the following is the likely diagnosis?

1- Acromegaly

2- Systemic mastocytosis

3- Hypothyroidism

4- Cushing's disease

5- Asthma

Answer & Comments

Answer: 2- Systemic mastocytosis

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Systemic mastocytosis is caused by mast cell
release of histamine in the skin or connective
tissue. It classically presents with episodes of
flushing, vomiting, diarrhoea and abdominal
pain.

Diagnosis can be confirmed by raised levels of
urinary N-methyl imidazole, blood
eosinophilia and thrombocytopenia.Total
serum tryptase levels of 20 ng/mL or higher in
a baseline serum sample is also suggestive of
systemic mast cell disease.

When a cutaneous lesion is stroked, it typically
urticates, becoming pruritic, edematous, and
erythematous. This change is referred to as
the Darier sign, which is explained by mast cell
degranulation induced by physical stimulation.

[Q: 109] MRCPass -
Gastroenterology

A 44 year old man presents with frequent
diarrhoea and upper abdominal pains. He has
had a partial gastrectomy 3 years ago for
upper Gl bleeding. He is now on high dose
omeprazole regularly. A repeat endoscopy
now shows two oesopnageal ulcers.

Whot is the appropriate investigation?

[Q: 110] MRCPass -
Gastroenterology

A 48 year old man presents with lethargy and
pruritus. He has lost one stone in weight over
the past two years.

He does not smoke. There is no family history
of bowel malignancy.

On examination he looks pale but is not
jaundiced. There is no hepatomegaly and
there are no signs of chronic liver disease.
Liver ultrasound shows small gallstones. The
gallbladder is not inflamed. There is no biliary
duct dilatation. Bilirubin is 18, ALT is 180 U/l,
ALP is 800 U/l. ANA and AMA are negative but
pANCA is positive.

What is the diagnosis?

1- Primary biliary cirrhosis

2- Cholangiocarcinoma

3- Primary sclerosing cholangitis

4- Wilson's disease

5- Gallstones

Answer & Comments

Answer: 3- Primary sclerosing cholangitis

1- Barium enema

2- Insulin tolerance test

3- H. pylori serology

4- Colonoscopy

5- Gastrin levels

Primary sclerosing cholangitis presents at this
age, there is cholestatic picture on the liver
function tests, but not necessarily high
bilirubin. pANCA is positive in about 90% of
patients with PSC. A small proportion of
patients (3%) will progress to
cholangiocarcinoma at a later age.

Answer & Comments

Answer: 5- Gastrin levels

Diarrhea and recurrent gastric ulceration is
common with Zollinger Ellison syndrome
(gastrinoma). There would be demonstrable
high fasting plasma gastrin levels. Gastrinomas
may occurs as part of a multiple endocrine
neoplasia syndrome type 1.

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[Q: 112] MRCPass -
Gastroenterology

A 65 year old woman complains of fevers,
weight loss, joint pains and diarrhoea. A
jejunal biopsy reveals flattened mucosa
containing periodic acid-Schiff (PAS) positive
macrophages.

What is the most likely diagnosis?

1- Coeliac disease

2- Campylobacter infection

3- Tropical sprue

MR cholangiogram showing stenoses and „ . , , ,.

, r . . , ... 4- Whipple s disease

irregularities of the hepatic ducts and bile

ducts in Sclerosing Cholangitis

5- Giardiasis

^ [Q: 111] MRCPass-

Answer & Comments

S Gastroenterology

Answer: 4- Whipple's disease

A 22 year old man presents with a 10 month
history weight loss, oral ulceration and
diarrhoea. A flexible sigmoidoscopy is
performed and a colonic biopsy was taken.

PAS stained macrophages on the jejunal
biopsy indicates a diagnosis of Whipple's
disease.

Which of the following histological features
would favour a diagnosis of Crohn's disease
over ulcerative colitis?

1- Lymphocyte infiltrate of lamina propria

2- Metaplastic polyps

3- Caseating granulomata

4- Crypt of lieberkuhn abscesses

5- Goblet cell mucus depletion

A 40 year man with chronic hepatitis C has
nonspecfic general deterioration.

On examination he has a temperature of 37.8
C, pressure of 100/70 mmHg and is jaundiced.

His investigations reveal:

Serum Sodium 129 mmol/l

[Q: 113] MRCPass -
Gastroenterology

Answer & Comments

Answer: 1- Lymphocyte infiltrate of lamina
propria

Crohn's disease is characterised by transmural
inflammation, neutrophil infiltrates, lymphoid
aggregates, fissures, preservation of crypt
architecture and noncaseating granulomata.

Serum potassium 4.2 mmol/l

Serum Urea 20 mmol/l

Serum Creatinine 350 micromol/l

bilirubin 65 micromol/l

AST 92 (10-40) U/l

Aik Phosphatase 250 (50-120) U/l

Albumin 30 (33-42) g/l

Ulcerative colitis is typified by mucosal
inflammation, general inflammatory cell
infiltration, goblet cell mucus depletion and
crypt abscesses.

Urine sodium 15 mmol/l
What is the likely diagnosis?
1- Hepatitis B infection

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2- Spontaneous bacterial peritonitis

3- Hepatorenal syndrome

4- Hepatocellular carcinoma

5- Discreet alcoholism

2- CT scan of the abdomen

3- X ray of the abdomen.

4- Small bowel follow through

5- Barium enema

Answer & Comments

Answer: 3- Hepatorenal syndrome

Answer & Comments

Answer: 2- CT scan of the abdomen

Hepatorenal syndrome (HRS) is the
development of renal dysfunction in patients
with severe liver disease (acute or chronic) in
the absence of any other identifiable causes of
renal pathology.

Tw o types of HRS have been described. Type
1 is mainly associated with acute liver failure
or alcoholic cirrhosis, but it can develop in any
other form of liver failure. It is characterized
by rapid deterioration of renal function, with
marked increase in serum creatinine and urea.
Hyponatremia and hyperkalemia are usual
findings. Type 2 is a more stable form.

Peritoneal dialysis, hemodialysis, and
hemofiltration remain controversial because
of their limited benefit. However, they are still
employed by certain centers in patients
awaiting liver transplantation.

[Q: 114] MRCPass -
Gastroenterology

A 30 year old lady presents with a long history
of abdominal pain and diarrhoea. She also
gives a history of recurrent mouth ulcers.
Recently the pain has become more intense,
she has begun to lose weight and has
developed fever with night sw eats and she
also complains of a rash over her legs.

On examination she is thin, she has clubbing
and erythema nodosum. On examination of
the abdomen a firm tender mass can be
palpated in the right iliac fossa.

In this patient , which of the following
investigations is most appropriate?

1- Colonoscopy

The clinical features in this patient points tow
ards a diagnosis of Crohn's disease. However,
the features of increased pain, fever sw eats
and a mass suggest the patient may have
developed an abscess in the right iliac fossa.
Hence, imaging this area with CT scan to
detect and treat the collection is the
investigation of choice.

A 60 year old woman has a 15 year history of
constipation. She undergoes a sigmoidoscopy
and rectal biopsy.

This shows epithelium with pigment laden
macrophages in lamina propria.

What is the likely cause of these findings?

1- Coeliac disease

2- Ulcerative colitis

3- Crohn's diseae

4- Mesenteric ischaemia

5- Laxative abuse

[Q: 115] MRCPass -
Gastroenterology

Answer & Comments

Answer: 5- Laxative abuse

Melanosis coli is usually associated with
chronic laxative use (senna), dark pigment is
deposited in the lamina propria of the colon. It
does not require medical or surgical
intervention and is considered to be a benign
pigmentation disorder.

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Melanosis coli due to laxative abuse (dark
appearance of colon)

[Q: 116] MRCPass -
Gastroenterology

A 45 year old man has a 10 year history of
type 2 diabetes mellitus. In the past he has
had fertility problems and has long standing
generalised joint pains. Recently, he has been
noted to have abnormal liver function tests.

The GP refers him to the clinic querying non¬
alcoholic fatty liver disease. On examination
his skin is tanned, there is loss of body hair,
gynaecomastia, hepatomegaly and testicular
atrophy.

How should this patient be treated?

1- Oral hypoglycaemics

2- Interferon

3- Ribavirin

4- Penicillamine

5- Venesection

Answer & Comments

Answer: 5- Venesection

The patient is likely to have
haemochromatosis in view of the history of
diabetes, arthropathy, deranged liver function
tests and bronze skin pigmentation. Ferritin
and liver biopsy will help to confirm the
diagnosis. Venesection is the best method of
depleting body iron stores. Treatment consists

of bi-weekly venesection removing
approximately 500 ml per week.

[Q: 117] MRCPass -
Gastroenterology

A 37 year old presents with a 10-day history of
loose stools and mild abdominal discomfort,
and recent onset of blood in stool. Ulcerative
colitis was suspected by the
gastroenterologist.

Which one of the following is the investigation
of choice?

1- Sigmoidoscopy

2- Colonoscopy

3- Barium enema

4- Radionuclide scintigraphy

5- Angiography

Answer & Comments

Answer: 2- Colonoscopy

Colonoscopy is the investigation of choice to
evaluate ulcerative colitis, features such as
loss of vascular pattern, erythema, oedema,
granular mucosa, blood, pseudopolyp,
erosion, ulceration are seen.

[Q: 118] MRCPass-
Gastroenterology

A 45 year old woman has been a heavy
alcoholic for 20 years, but has cut dow n on
drinking for the past year.

She has abdominal pains, malaise and nausea.
On examination she had moderate amounts of
ascites and generalised abdominal tenderness.

Investigations show :
Haemoglobin 12 g/dL
WCC 14 x 10 9 /L

prothrombin time 22 s (<15s)
serum albumin 25 g/L (37-49)
serum total bilirubin 50 micromol/L (1-22)

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ascitic fluid protein 27 g/L

ascitic fluid lactate 35 mg/dL

ascitic fluid amylase normal

ascitic fluid white cell count 650 cells/mL

Whot is the likely reason for her deterioration ?

1- Wilson's disease

2- Spontaneous bacterial peritonitis

3- Hepatoma

4- Hepatic vein thrombosis

5- Pancreatic abscess

Answer & Comments

Answer: 2- Spontaneous bacterial peritonitis

Abdominal tenderness is found in more than
50% of patients with Spontaneous Bacterial
Peritonitis. Findings on the abdominal
examination can range from mild tenderness
to overt rebound and guarding.

Traditionally, three fourths of SBP infections
are caused by aerobic gram-negative
organisms (50% of these being Escherichia
coli), and one fourth of these infections are
due to aerobic gram-positive organisms (
streptococcal species).

An ascitic fluid neutrophil count of >250
cells/mL and ascites lactate level of >25 mg/dL
are the single best predictors of SBP. A
combination of an aminoglycoside and
ampicillin or cefotaxime can be used.

[Q: 119] MRCPass -
Gastroenterology

A 33 year lady presents with intense pruritus
in her third trimester of pregnancy. Clinically
there are no abnormalities apart from scratch
marks.

Investigations reveal: ALT 150 U/L, Alkaline
phosphatase 320 U/L, bilirubin 70
micromoles/I. FBC is normal.

What should be the next management step?

1- Hepatitis test

2- Liver biopsy

3- Intrahepatic shunting

4- Ursodeoxycholic acid

5- Azathioprine

Answer & Comments

Answer: 4- Ursodeoxycholic acid

The patient has intrahepatic cholestasis of
pregnancy. Treatment is symptomatic with
ursodeoxycholic acid (cholestyramine and high
dose steroids can also be used). The most
common symptom of intrahepatic cholestasis
of pregnancy is itching which typically
develops in the third trimester of pregnancy.

The itching begins on the palms and soles, and
then spreads to the rest of the body. The rash
of ICP is caused by scratching the intensely
itchy skin. Jaundice occurs in 10% to 15% of
cases and typically develops 2 to 4 weeks after
the itching starts. After delivery, both itching
and jaundice resolve spontaneously. ICP does
recur with subsequent pregnancies in 40% to
50% of women.

A 35 year old man presents with epigastric
pains which are burning in nature and worse
at night. He undergoes endoscopy and the
investigation confirms a diagnosis of gastro-
oesophageal reflux disease (GORD).

Which of the following is most likely to relieve
his symptoms?

1- Omeprazole

2- Lactulose

3- Brandy

4- Ibuprofen

5- Diclofenac

[Q: 120] MRCPass -
Gastroenterology

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Answer & Comments

_ ^

[ Q: 122 ] MRCPass-

Answer: 1- Omeprazole

-JF

Gastroenterology

The most effective drugs in Gastro-
oesophageal reflux are proton pump inhibitors
such as omeprazole. H2 receptor antagonists
(ranitidine) and Cisapride have also been
shown to be effective. Nitrates and caffeine
can also relieve symptoms by relaxing lower
oesophageal tone.

A 55 year old woman presents with a 6 month
history of bloody diarrhoea. She has not had
any previous admissions or serious illnesses.
On examination, her abdomen is distended
and tender on the left side.

Rectal examination reveals small amount of
faeces.

[Q: 121] MRCPass -
Gastroenterology

A 35 year old man is referred for lethargy to
the gastroenterologist. His GP has recently
diagnosed diabetes and he is on insulin
injections. He drinks 12 units of alcohol per
week. On examination he has a grey
discolouration to his skin. There are no signs
of chronic liver disease, but he has a smooth
palpable liver edge of three finger breadths
below the costal margin.

Blood tests show a Hb 11.0 g/dl WCC 15.6 x
10 9 /l. platelets 450 x 10 9 /l. Sodium is 139
mmol/I, potassium is 4.6 mmol/l, urea 8.6
pmol/l. creatinine 130 pmol/l. CRP is 35 mg/I.

What is the next best further investigation?

1- Colonoscopy

2- X ray of abdomen

3- Sigmoidoscopy

4- CT of the abdomen

5- MRI of abdomen

His blood tests show a Hb 13.5 g/dl, WCC of
12 x 10 9 /L, platelets 145 x 10 9 /L, sodium 133
mmol/l, potassium 4.5 mmol/l, urea 9 pmol/l,
creatinine pmol/l bilirubin 23 pmol/l, ALT 150
U/l, ALP 110 U/l.

Which further test is most likely to yield the
diagnosis?

1- Serum copper and caeruloplasmin

2- Serum ferritin

3- Ultrasound of abdomen

4- Serum amylase

5- Secretin test

Answer & Comments

Answer: 2- Serum ferritin

Haemochromatosis is described. There is grey
pigmentation of the skin and hepatomegaly.
The condition can be made worse when there
is additional alcohol intake.

Answer & Comments

Answer: 2- X ray of abdomen

The imperative management is to exclude a
toxic megacolon. This is a patient with bloody
diarrhoea who could have ulcerative colitis,
and a distended tender abdomen indicates
possible acute abdomen.

Toxic Megacolon

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A 40 year old man is being investigated for a 3
year history of arthralgia. On examination, his
skin colour was normal and there was no
evidence of jaundice or hepatomegaly. He has
the following results:

Alanine aminotransferase 32 U/L (5-35)

Aspartate aminotransferase 28 U/L (1-31)

Fasting plasma glucose 7.4 (3.0-6.0)

Ferritin 550 ug/L (15-300)

What is the next best investigation?

1- Bone marrow biopsy

2- Transferrin saturation

3- Copper and caeruloplasmin

4- Serum transferrin receptors

5- Liver biopsy

Answer & Comments

Answer: 2- Transferrin saturation

Serum ferritin has many false positives and
the patient should have the transferrin
saturation done. The diagnosis of iron
overload and potentially hereditary
hemochromatosis should be suspected in men
whose transferrin saturation is greater than
55% and in women whose transferrin
saturation is greater than 50%.

He has also noticed that he is developing
itchiness and a generalised rash.

Which one of the following skin conditions is it
likely to be?

1- Erythema marginatum

2- Dermatitis herpetiformis

3- Erythema chronicum migrans

4- Pityriasis rosea

5- Tinea versicolor

Answer & Comments

Answer: 2- Dermatitis herpetiformis

In coeliac disease, dermatitis herpetiformis
manifests as a pruritic rash. It is a chronic,
extremely itchy rash consisting of papules and
vesicles. Dermatitis herpetiformis is associated
with sensitivity of the intestine to gluten in the
diet (celiac sprue). The vesicles or papules
appear on the elbow s, knees, back, and
buttocks (pressure points). It may also present
as a patch of red skin with little water blisters
scattered about.

J k ki M

. # P 94

Y ->

k t

Jfh

[Q: 123] MRCPass
Gastroenterology

In patients with confirmed hemochromatosis,
one of 2 gene defects described (CYS282
tyrosine or H63D mutation) is found in >85%
of patients of Northern European descent.

[Q: 124] MRCPass -
Gastroenterology

A 35 year man has abdominal pains, weight
loss and diarrhoea. He was subsequently
found to be lactose intolerant and a small
bowel biopsy showed changes consistent with
in coeliac disease.

Dermatitis herpetiformis

[Q: 125] MRCPass-
Gastroenterology

A 40 year old man has had intermittent
diarrhoea and joint pains for 6 months. On
examination he has limited vertical eye
movements.

Which pathogen is the likely cause of his
symptoms?

1- Salmonella enteritidis

2- Cryptosporidium

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3- Trophyrema whippleii

4- Prion protein

5- Syphillis

Answer & Comments

Answer: 3- Trophyrema whippleii

Whipple's disease characteristically occurs in
middle-aged men, who present with weight
loss, fever, abdominal pain, arthralgias and
intestinal symptoms of diarrhea and
malabsorption.

Confusion, memory loss, or uncontrolled eye
movements indicate that the infection has
travelled to the CNS.

Trimethoprim - sulfamethoxazole is
recommended; treatment is continued for one
year.

[Q: 126] MRCPass -
Gastroenterology

A 40 year old man presented with a 5 day
history of bloody diarrhoea. On examination,
he was apyrexial, jaundiced and pale. There
was no organomegaly but there was mild
lower abdominal tenderness.

Investigations reveal:

Haemoglobin 8.1 g/dL

White cell count 17.5 x 10 9 /l_

Platelets 70 x 10 9 /l_

urea 11 pmol/l

creatinine 220 pmol/l

aspartate aminotransferase 110 IU/L

Prothrombin time 12s (11.5-15.5)

Blood film shows fragmented red cells

What is the likely diagnosis?

1- Ulcerative colitis

2- Escherichia coli 0157 colitis

3- Salmonella enterocolitis

4- Campylobecter colitis

5- Yersinia colitis

Answer & Comments

Answer: 2- Escherichia coli 0157 colitis

The combination of haemolytic anaemia and
thrombocytopaenia is consistent with
haemolytic uraemic syndrome (HUS - TTP).
The most likely cause of diarrhoea is E coli
0157.

Hemolytic uremic syndrome (HUS) is
characterized by the triad of microangiopathic
hemolytic anemia, thrombocytopenia, and
acute renal failure. Diarrhea and upper
respiratory infection are the most common
precipitating factors. Other bacterial agents
include Shigella, Salmonella, Yersinia, and
Campylobacter species.

A 40 year old man visit his GP with symptoms
of flushing and dizziness. He also has watery
diarrhoea several times a month. On
examination he has a systolic murmur in the
tricuspid area and a parasternal heave over
the left sternal edge. A 24 hour urine shows
raised 5HT levels.

What is the diagnosis?

1- Tropical Sprue

2- Crohn's disease

3- Phaeochromocytoma

4- Carcinoid syndrome

5- Pernicious anaemia

[Q: 127] MRCPass -
Gastroenterology

Answer & Comments

Answer: 4- Carcinoid syndrome

Carcinoid syndrome is diagnosed by raised
urinary 5-HT levels. A precursor of 5HT,
tryptophan is highly metabolised and
consequently niacin deficiency (pellagra)
occurs. The rest of the D's dementia,

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dermatitis (a photosensitive rash) and
diarrhoea occur in pellagra.

Flushing seen in carcinoid syndrome

[Q: 128] MRCPass -
Gastroenterology

A 65 year old man is investigated for lower
back pain. He also complains of weight loss
and fevers. On review ing his history, he has
been told before that he has ankylosing
spondylitis.

On admission, his blood tests show a urea of
25 pmol/l and a creatinine of 350 pmol/l. An
ultrasound of the kidneys shows
hydronephrosis bilaterally. CT scan shows
fibrotic para-aortic masses.

Which of the following is the diagnosis?

1- Carcinoid syndrome

2- Retroperitoneal fibrosis

3- Amyloidosis

4- Metastatic bladder cancer

5- Lymphoma

Answer & Comments

Answer: 2- Retroperitoneal fibrosis

The symptoms of fevers, weight loss and
lower back pain are classical for
retroperitoneal fibrosis. There is an

association with inflammatory conditions such
as SLE, rheumatoid arthritis, ankylosing
spondylitis, Hashimoto's thyroiditis and
glomerulonephrosis. CT or MRI shows fibrotic
para-aortic masses causing ureteric
obstruction.

[Q: 129] MRCPass -
Gastroenterology

A 20 year old nurse has recently been
diagnosed with hepatitis B and has had
serology measured.

Which of the following is the best marker of
infectivity?

1- DsDNA

2- HbcAg

3- HBeAg

4- HBsAg

5- HBs Ab

Answer & Comments

Answer: 3- HBeAg

HBeAg (not HBeAg) is the best marker of
infectivity, and is used as an important criteria
for selection of patients who have chronic
hepatitis B for interferon (a-2B) therapy. HBV
DNA and HBeAg levels are measured in
response to the therapy and undetectable
levels are considered successful treatment.

HB#Ag +-

Anti-HBe
HBsAg *

+ ±

+ +
+ ±

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[Q: 130] MRCPass -
Gastroenterology

A 60 year old woman with arthritis was
referred for investigation of iron deficiency
anaemia. Endoscopy several superficial antral
erosions. A small bowel biopsy showed mild
villous blunting, apopotic bodies, occasional
eosinophils, mild increase in chronic
inflammatory cells. Colonoscopy was
unremarkable.

Whot is the likely cause of the anaemia?

1- Whipple's disease

2- Ulcerative colitis

3- Nonsteroidal anti inflammatory drugs

4- Myelodysplastic syndrome

5- Coeliac disease

Answer & Comments

Answer: 3- Nonsteroidal anti inflammatory
drugs

Superficial ulceration on the OGD suggests
that the anaemia is due to NSAID therapy.
Small bowel biopsy is to exclude coeliac
disease, in this case there is no villous atrophy.

Colonoscopy is to exclude angiodysplasia and
a tumour.

[Q: 131] MRCPass -
Gastroenterology

A 65 year old lady has rheumatoid arthritis. In
the last 6 months she has become more
lethargic and undergoes evaluation. On
examination, she has palpable splenomegaly.

Her blood tests reveal Hb of 8.5 g/dl, WCC of 3
x 10 9 /I with a neutrophil count of 0.9, and
platelet count of 160 x 10 9 /L.

What is the diagnosis?

1- Aplastic anaemia

2- Juvenile chronic arthritis

3- Haemochromatosis

4- Felty's syndrome

5- Ankylosing spondylitis

Answer & Comments

Answer: 4- Felty's syndrome

Felty's syndrome consists of a triad of
neutropenia, hypersplenism and rheumatoid
arthritis, which is the most likely unifying
diagnosis Although the pathophysiology of
Felty syndrome is not fully known, evidence
points to splenic sequestration and
subsequent granulocyte destruction.

The extra-articular manifestations of RA (eg,
rheumatoid nodules, pleuropericarditis,
vasculitis, peripheral neuropathy, episcleritis,
other forms of eye involvement, Sjogren
syndrome, adenopathy, skin ulcers) are more
common in patients who develop Felty
syndrome.

[Q: 132] MRCPass-
Gastroenterology

A 60 year old woman presents with a history
of worsening dysphagia over many years.
Recently there were episodes of atypical
central chest discomfort and cough. She also
mentioned occasional regurgitation of her
food.

An X ray shows narrow ing at the level of the
gastroesophageal junction.

What is the likely diagnosis?

1- Oesophageal carcinoma

2- Pharyngeal pouch

3- Oesophagitis

4- Barrett's oesophagus

5- Achalasia

Answer & Comments

Answer: 5- Achalasia

Achalasia presents often in 3rd to 5th decade.
The classical triad of achalasia is dysphagia

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(difficulty swallowing) to fluids and later
solids, regurgitation of undigested food, and
chest pain. Other symptoms may include
difficulty belching, frequent hiccups, cough.
30% have a nocturnal cough due to aspiration
of oesophageal contents.

An X ray or barium Swallow shows narrow ing
at the level of the gastroesophageal junction
of the lower esophagus and various degrees of
megaesophagus (esophageal dilation) as the
esophagus is gradually stretched by retained
food. Manometry is the key test for
establishing the diagnosis. A probe measures
the pressure waves in different parts of the
esophagus and stomach during the act of
swallowing.

Achalasia

[Q: 133] MRCPass -
Gastroenterology

A 35 year old patient has had a hepatitis test
for investigation of jaundice. He has a positive
Hep BsAg (HBsAg) and has IgM antibodies to
Hep Bcore (anti-HBc).

What is he likely to have?

1- Hepatitis D infection

2- Seroconversion illness

3- Chronic hepatitis B infection

4- Acute hepatitis B infection

5- Recent vaccination

Answer & Comments

Answer: 4- Acute hepatitis B infection

The positive anti-HBc (IgM) and HBsAg
suggests acute infection. When the infection
resolves, HBsAg becomes negative and anti-
HBc (IgG) is positive. In patients who have
been vaccinated, HBsAg is negative and anti-
HBs is positive.

[Q: 134] MRCPass -
Gastroenterology

A 25 year old woman has type 1 diabetes. She
has weight loss of 1 stone over the past 3
months, and irregular menstrual cycles. Her
bowel habit has been unchanged. On
examination her BMI was 24 kg/m 2 .

Investigations show a haemoglobin of 8.1 g/dl
with a MCV of 69 fl.

Which is the likely diagnosis?

1- Heavy Periods

2- Bacterial overgrowth

3- Crohn's disease

4- Dietary iron deficiency

5- Coeliac disease

Answer & Comments

Answer: 5- Coeliac disease

Coeliac disease is most likely as this patient
autoimmune phenomenon (diabetes), with an
iron deficiency anaemia and no symptoms of
diarrhoea. Patients with type 1 diabetes are at
up to six times greater risk of having coeliac

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disease. Antibodies to gliadin should be sent
and the diagnosis of coeliac disease can be
confirmed by taking a biopsy from the
duodenum (small bowel just beyond the
stomach) which will show villous atrophy.

2- Wilson's disease

3- Budd Chiari syndrome

4- Alpha 1 antitrypsin deficiency

5- Alcoholic liver disease

[Q: 135] MRCPass -
Gastroenterology

A 50 year old alcoholic patient presents with
confusion and severe derangement of liver
function. On examination, his MMSE score is
22 / 30. He has signs of spider naevi, jaundice
and gross ascites.

Which one of the following features defines
fulminant acute hepatic failure?

1- Spider naevi

2- Leukonychia

3- Jaundice

4- Ascites

5- Encephalopathy

Answer & Comments

Answer: 5- Encephalopathy

By definition, fulminant hepatic failure is
associated with encephalopathy.

Prognosis is poor irregardless of speed of
disease progression. It typically presents
acutely when previous hepatic disease is
unknown. Commonest causes in the UK are
paracetamol overdose and hepatitis.

[Q: 136] MRCPass -
Gastroenterology

A 50 year old woman has symptoms of
pruritis, steatorrhoea and easy bruising. On
examination, she is jaundiced and had
xanthelasmata. Her skin was pigmented and
has 8 spider naevi. There is also
hepatosplenomegaly.

What is the likely overall diagnosis?

1- Primary biliary cirrhosis

Answer & Comments

Answer: 1- Primary biliary cirrhosis

She has chronic liver disease with portal
hypertension. The 2 main conditions causing
pigmentation along with signs of chronic liver
disease are primary biliary cirrhosis (PBC) &
haemochromatosis. Xanthelasmata are
common in PBC but not in haemochromatosis.
PBC is a chronic cholestatic inflammatory liver
disease, aetiology of which probably
autoimmune. It commonly affects middle
aged women.

Serum AntiMitochondrial Antibody is positive
in 95 % of cases.

Primary biliary cirrhosis

[Q: 137] MRCPass -
Gastroenterology

A 45 year old lady has a two month history of
nausea, jaundice and dark urine. She also has
a history of arthralgia and autoimmune
thyroid disease.

On examination, her abdomen was non¬
tender with 4 cm hepatosplenomegaly.

Investigations reveal AST 1675 U/L (5 - 40),
ALT 3900 U/L (5 -40), GGT 179 U/L (10 - 60),
bilirubin 65 (1-22) pmol/l, increase in total
globulin and smooth muscle antibodies are
positive. Serum immunoglobulins were

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elevated with IgG of 2390 mg/dl (694 - 1618)
and IgA of 306 mg/dl (68 - 263). Anti-nuclear
antibodies (ANA) were positive at 1:320 titer
in a homogenous speckled pattern. Anti¬
smooth muscle and liver-kidney microsomal
antibodies were positive.

Whot is the likely diagnosis?

1- Wilson's disease

2- Cholangiocarcinoma

3- Primary biliary cirrhosis

4- Autoimmune hepatitis

5- Crohn's disease

Answer & Comments

Answer: 4- Autoimmune hepatitis

In autoimmune hepatitis, response to steroids
is excellent and it improves five-year survival,
but does not prevent development of
cirrhosis. Azathioprine is an useful adjunct to
steroids and allows reduction of steroid doses,
thus reduces the risk of osteoporosis.

Chronic autoimmune hepatitis is a chronic
hepatitis of unknown origin that
predominantly affects young and middle aged
women. It is associated with HLA types Al, B8,
DR3 and Dw 3. Presentation is usually
insidious. The patient may be generally unwell
and jaundiced. Amenorrhoea is common.
Examination may reveal signs of chronic liver
disease, hepatomegaly and splenomegaly.

Investigations show raised inflammatory
markers and serum transaminases. ANA and
smooth muscle antibodies are usually positive.

Where is gastrin produced?

1- Oesophagus

2- Colonic mucosa

3- G cells of gastric antrum

4- Islet cells

5- Small intestine

Answer & Comments

Answer: 3- G cells of gastric antrum

Gastrin is produced in 2 forms by the G cells of
gastric antrum. It stimulates parietal cells
produce hydrochloric acid. Its production is
stimulated by neural reflex pathways and also
by direct effect of digested peptides on the G
cells. It also stimulates the production of
bicarbonate.

A 65 year old woman has a diagnosis of insulin
dependent diabetes mellitus (poorly
controlled) for 25 years. She complains of
repeated episodes of abdominal pain
following meals. These episodes have become
more frequent over the past 3 months. There
is no abdominal tenderness on palpation.

Which of following finding is likely be present?

1- Autonomic neuropathy

2- Hepatitis

3- Mesenteric artery occlusion

4- Chronic pancreatitis

5- Acute pancreatitis

[Q: 139] MRCPass
Gastroenterology

[Q: 138] MRCPass -
Gastroenterology

A 50 year old man presents has a 6 month
history of severe indigestion. 3 years ago he
had a duodenal ulcer seen on endoscopy.

Investigations reveal:

Fasting gastrin 150 pmol/L (<55)

Answer & Comments

Answer: 3- Mesenteric artery occlusion

Diabetes, especially Type 2 diabetes is
associated with macrovascular disease. If the
mesenteric artery is stenosed or occluded
then lack of blood flow to the bowel will
produce ischaemic pains.

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[Q: 140] MRCPass -
Gastroenterology

A 60 year old man is investigated for weight
loss and dyspepsia. Endoscopic examination
reveals an ulcerated lesion in stomach. Biopsy
shows the presence of a low grade mucosa
associated lymphoma and Helicobacter pylori.
CT of chest & abdomen shows no metastases.

Whot is the best treatment option for this
patient?

1- Radiotherapy

2- Helicobacter pylori eradication

3- Bilroth's gastrectomy

4- Oral chlorambucil

5- CHOP therapy

A MALT tumour

Answer & Comments

Answer: 2- Helicobacter pylori eradication

The diagnosis is a gastric MALT tumour. These
are usually marginal zone B cell lymphomas
associated an excellent prognosis.

MALT lymphoma is the third most common
type of non-Hodgkin lymphoma, although it
only accounts for about 7-8% of these
tumours. MALT lymphomas have been
described at almost all extra-nodal sites, but
are most commonly found in the
gastrointestinal tract (stomach is the
commonest).

Low grade gastric MALT tumours which are
associated with Helicobacter Pylori infection
respond in over 80% of cases to helicobacter
eradication. A proportion of patients will not
respond to eradication therapy alone and will
go on to more conventional anti-lymphoma
therapies such as cyclophosphamide,
chlorambucil, nucleoside analogues or
radiotherapy.

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[ Q: 141 ] MRCPass - Rheumatology

#5 -

A 35 year old man presents with a 6
month history of arthralgia, mouth ulceration
and eye irritation. On examination, he had
some ulceration in the mouth, bilaterally
swollen wrists and reduced range of
movements of both knees.

His investigations showed: white cell count 11
x 10 9 /L, C reactive protein 100 mg/dl,
Rheumatoid factor negative.

What is the likely diagnosis?

1- Reiter's syndrome

2- Sjogren's syndrome

3- Ankylosing spondylitis

4- Behcet's syndrome

5- Sarcoidosis

Answer & Comments

Answer: 4- Behcet's syndrome

Behcet's syndrome is a multisystem disorder
characterised by recurrent oral genital
ulceration, eye lesions (anterior and posterior
uveitis or retinal vasculitis), skin lesions,
(erythema nodosum, papulopustular lesions
folliculitis) and a positive pathergy test.

The pathergy phenomenon is considered an
outstanding feature of Behcet disease.
Following a needle prick or intradermal
injection with saline or dilute histamine, the
puncture site becomes inflamed and develops
a small sterile pustule due to hyperactivity of
the skin to any intracutaneous insult.

Oral Ulceration in Behcet's disease

^ [ Q: 142 ] MRCPass - Rheumatology

/ -

# A 33 year old female with systemic

lupus erythematosis has arthralgia involving
her upper limbs. She also has a butterfly facial
rash and a rash on the trunk.

Urine dipstick shows no Proteinuria or
haematuria. Her renal function is normal.

Which one of the following medications is
most appropriate?

1- Methotrexate

2- Prednisolone

3- Azathioprine

4- Hydroxychloroquine

5- Cyclosporin

Answer & Comments

Answer: 4- Hydroxychloroquine

NSAIDs and hydroxychloroquine are used for
skin involvement and arthritis.

NSAIDs are used for mild disease.

Hydroxychloroquine is useful for disease not
controlled by NSAIDS. Steroids are used in
moderate to severe disease.

Immunosuppressive treatments such as
azathioprine and cyclophosphamide are used
typically w hen there is renal or cerebal

disease.

^ [ Q: 143 ] MRCPass - Rheumatology

/ -

A 75 year old woman with long¬
standing Rheumatoid arthritis has great

difficulty walking and comments that both her
legs are stiff and 'jumpy'.

What is the most likely cause of the
presentation?

1- Ankylosing spondylitis

2- Syringomyelia

3- Osteoporosis

4- Atlanto-axial instability

5- Disc compression

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Answer & Comments

Answer: 4- Atlanto-axial instability

Cervical cord compression due to atlanto-axial
instability is the most likely cause of UMN
nerve weakness.

[ Q: 144 ] MRCPass - Rheumatology

A 50 year old woman has severe
rheumatoid arthritis. She is admitted with
worsening breathlessness.

She is currently on ibuprofen, methotrexate,
celecoxib, and paracetamol. On examination,
she has features of rheumatoid changes in her
hands and looks pale. There is no palpable
lymphadenopathy and no abdominal masses.

Investigations showed that her Hb level is 7.8
g/dl with a MCV of 90, WCC 2.1 x 10 9 /l and
platelets 55 x 10 9 /l.

Reticulocyte count is 0.3%(0.5% to 1.5%).

Whot is the likely couse of the onoemio?

1- NSAID use and Gl bleed

2- Treatment with celecoxib

3- Treatment with methotrexate

4- Anaemia of chronic disease

5- Felty's syndrome

Answer & Comments

Answer: 3- Treatment with methotrexate

The patient has an aplastic anaemia which can
be caused by methotrexate or azathioprine,
DMARDs (penicillamine or gold).

Abnormally low reticulocyte count can be
attributed to chemotherapy, aplastic anemia,
pernicious anemia, bone marrow malignancies
and lowerythropoietin levels.

[ Q: 145 ] MRCPass - Rheumatology

A 65 year old woman presents with
dry eyes and a dry mouth. Her investigations
show : ANA strongly positive (1:1600),

antiRo/SSA antibodies strongly positive,
rheumatoid factor positive, IgG markedly
elevated at 42 g/l

(normal <15 g/l), IgM and IgA levels are
normal.

Whot is the likely diagnosis?

1- Monoclonal gammopathy of unknown
significance

2- Primary Sjogren's Syndrome

3- Systemic Lupus Erythematosus

4- Reiter's syndrome

5- Polyarteritis Nodosa

Answer & Comments

Answer: 2- Primary Sjogren's Syndrome

The clinical features and are consistent with
primary Sjogren's Syndrome.

Hypergammaglobulinaemia is present in 80%
of individuals. ANA, AntiRo/SSA antibodies are
present in approximately 90% of individuals
and there can also be a weakly positive
rheumatoid factor.

Dry mouth seen in Sjogren's syndrome

[ Q: 146 ] MRCPass - Rheumatology

A 55 year old female has been on
long-term steroids for chronic obstructive
pulmonary disease. She complains of pain in
her right groin radiating down the
anteromedial thigh. She has an antalgic gait.

On examination of the hip, there is decreased
range of movement especially flexion,
abduction and internal rotation.

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What is the likely diagnosis?

1- Osteoarthritis

2- Rheumatoid arthritis

3- Metastatic hip lesion

4- Avascular necrosis of the femoral head

5- Hairline fracture

Answer & Comments

Answer: 4- Avascular necrosis of the femoral
head

In a patient on long term steroids presenting
with groin pains radiating to the thigh
associated with an antalgic gait and decreased
range of movement of the hip, the most likely
diagnosis is avascular necrosis of the femoral
head.

In this condition, MRI is the most sensitive and
specific technique and is useful for early
diagnosis before collapse of bone occurs. CT
scan and x-ray are useful to rule out advanced
disease if duration is not clear. Bone scanning
is more sensitive than x-ray but is non-specific.

cough. The oxygen saturation was found be
85% on air.

The chest x ray shows a diffuse bilateral
interstitial infiltrate.

Blood cultures and sputum cultures are
negative.

Which drug is likely to have caused this
adverse effect?

1- Cyclosporin

2- Cyclophosphamide

3- Gold

4- Methotrexate

5- Sulphasalazine

Answer & Comments

Answer: 4- Methotrexate

Pneumonitis is a serious and unpredictable
side-effect of treatment with methotrexate
(MTX) that may become life-threatening.
Chest radiography reveals a diffuse interstitial
or mixed interstitial and alveolar infiltrate,
with a predilection for the lower lung fields.

Pulmonary function tests show a restrictive
pattern with diminished diffusion capacity.
Lung biopsy reveals cellular interstitial
infiltrates, granulomas or a diffuse alveolar
damage pattern accompanied by perivascular
inflammation.

[ Q: 148 ] MRCPass - Rheumatology

A 65 year old man presents has
recently developed an acutely painful right
knee. On examination, he had a temperature
of 37.2°C a hot and swollen right knee.

MRI showing avascular necrosis of the femoral

head

[ Q: 147 ] MRCPass - Rheumatology

A 60 year old woman on treatment
for longstanding rheumatoid arthritis presents
with breathlessness. She complains of a dry

His white cell count which was raised at 14 x
10 9 /L. A knee X ray showed reduced joint
space and chondrocalcinosis.

Culture of aspirated fluid showed no growth.

What is the likely diagnosis?

1- Psoriatic arthropathy

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2- Rheumatoid arthritis

3- Pseudogout

4- Septic arthritis

5- Osteomalacia

5- Ankylosing spondylitis

Answer & Comments

Answer: 2- Haemochromatosis

Answer & Comments

Answer: 3- Pseudogout

The clinical picture is typical of pseudogout.
Calcification of the articular cartilage would be
consistent and the culture results excludes
septic arthritis. The diagnosis can be
confirmed by the presence of calcium
pyrophosphate crystals in joint fluid
demonstrating a positive birefringence under
polarised light.

The history of abdominal pain together with
skin pigmentation and hepatomegaly suggest
the patient has haemochromatosis.
Haemochromatosis is associated with
chondrocalcinosis, which commonly affects
the 2nd and 3rd metacarpophalangeal joints.
The acute arthropathy is likely to be
pyrophosphate crystal arthritis.

[ Q: 150 ] MRCPass - Rheumatology

A 70 year old man presents with
bony swellings of the DIP joints on both
hands. They were painful a year ago but are
now painless.

The most likely diagnosis is :

1- Heberden's nodes

2- Bouchard's nodes

3- Osier's nodes

Calcium pyrophosphate crystals

[ Q: 149 ] MRCPass - Rheumatology

A 60 year old man presents with a
painful swollen left knee as well as pain and
stiffness of both his hands.

On examination his skin is pigmented. There is
tenderness and swelling of the 2nd and 3rd
metacarpophalangeal joints of both hands, he
has hepatomegaly of 8 cm below the costal
margin.

His knee is swollen and aspiration of the joint
yields turbid, straw coloured fluid.

Which one of the following diagnosis is likely?

1- Wilson's disease

2- Haemochromatosis

3- Pseudohypoparathyroidism

4- Pseudopseudohypoparathyroidism

4- Gouty tophi

5- Charcot's joints

Answer & Comments

Answer: 1- Heberden's nodes

The most likely diagnosis is osteoarthritis. At
the DIP joints, swelling are known as

Heberden's nodes and at the PIP joints, they
are known as Bouchard's nodes.

Heberden's node

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[ Q: 151 ] MRCPass - Rheumatology

f - -—

# A 60 year old man presents with
gouty tophi. He has been commenced on
allopurinol but develops severe joint pains 3
days later. On examination, he has a
temperature of 39°C and erythematous
swelling of his wrists, knees and ankles.

Investigations reveal: urate 0.6 (0.23-0.45),
creactive protein 180 mg/L.

Which of the following is likely to hove caused
the presentation?

1- Allopurinol

2- Colchicine

3- Prednisolone

4- Pseudogout

5- Septic arthritis

What is the likely diagnosis?

1- Compartment syndrome

2- Deep vein thrombosis

3- Reflex sympathetic dystrophy

4- Raynaud's phenomenon affecting the leg

5- Venous varicosities

Answer & Comments

Answer: 3- Reflex sympathetic dystrophy

This clinical scenario is compatible with a
diagnosis of reflex sympathetic dystrophy or
complex regional pain syndrome following the
previous injury. Reflex sympathetic dystrophy,
also known as RSD, is a condition of burning
pain, stiffness, swelling, and discoloration of
the affected area.

Answer & Comments

Answer: 1- Allopurinol

Allopurinol blocks uric acid production and is
the drug most often used in long-term
treatment for older patients and
overproducers of uric acid. Allopurinol is taken
orally once a day in doses of 100 mg to 600
mg, depending on the patient's response to
treatment.

Between 3% to 5% of patients experience
leukopenia, thrombocytopenia, diarrhea,
headache, and fever.

[ Q: 152 ] MRCPass - Rheumatology

A 35 year old retired athlete
presents with severe burning pain affecting
the right leg and foot. 4 months earlier, he
had several arthroscopic washouts for septic
arthritis affecting his right knee, which
followed an injury.

Examination reveals a reduced range of
movement of the right knee and ankle. There
was diffuse swelling of the right leg and foot
with overlying cool, scaly skin.

The pain is often severe and disproportionate
to the signs and follow s a non-anatomic
distribution. The skin changes are due to the
associated autonomic dysfunction.

Reflex sympathetic dystrophy affecting the

right foot

•i

[ Q: 153 ] MRCPass - Rheumatology

A 75 year old has had increasing
back and leg pains several years. X rays reveal
bony sclerosis of sacroiliac, lower vertebral
and upper tibial regions. He mentions greater
difficulty hearing over the recent years.

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Blood tests reveal an elevated serum alkaline
phosphatase.

What is the likely diagnosis?

1- Paget's disease of bone

2- Osteoarthritis

3- Osteomalacia

4- Monoclonal gammapothy of uncertain
significance

5- Multiple myeloma

Answer & Comments

Answer: 1- Paget's disease of bone

In Paget's disease, onset of symptoms is
usually insidious, with pain, stiffness, bone
deformity, headaches, decreasing auditory
acuity, and increasing skull size.

^ [ Q: 154 ] MRCPass - Rheumatology

sit -

# A 55 year old patient presents with a
two week history of pain and stiffness in her
shoulders and wrists. The symptoms improve
over the day. On examination, there was
synovitis of both wrists and proximal muscle
wasting. Her ESR was 40 mm/hr.

What is the likely diagnosis?

1- Dermatomyositis

2- Systemic lupus erythematosus

3- Rheumatoid arthritis

4- Polymyalgia rheumatica

5- Osteoarthritis

Answer & Comments

Answer: 3- Rheumatoid arthritis

Signs may be bitemporal skull enlargement
with frontal "bossing," dilated scalp veins,
nerve deafness in one or both ears, angioid
streaks in the fundus of the eye, and
anterolateral bow ing of the thigh or leg with
w armth and periosteal tenderness.

Pagetic lesions are metabolically active and
highly vascular and may lead to high-output
heart failure.

Deformities may develop from bow ing of the
long bones or osteoarthritis of adjacent joints.

Pathologic fractures may be the presenting
finding. Characteristic x-ray findings include
increased bone density, abnormal
architecture, cortical thickening, bow ing, and
overgrowth.

Biochemistry includes elevated serum alkaline
phosphatase (or bone-specific alkaline
phosphatase) and increased urinary excretion
of pyridinoline cross-links. Serum calcium and
phosphorus levels usually are normal, but
serum calcium may increase during bed rest.

In a middle aged female, acute arthritis of
shoulders and wrists along with synovitis are
highly suggestive of acute Rhematoid Arthritis.

Synovitis involving the wrist in rheumatoid

arthritis

[ Q: 155 ] MRCPass - Rheumatology

A 45 year old woman presents with
numbness and weakness of her upper and
lower limbs. She developed asthma at the age
of 30.

On examination she looks unwell. She has
palpable purpura over her face and over her
elbows and knees.

On neurological examination she has a right
sided wrist drop and there is weakness of

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dorsiflexion of her right foot. Sensation is also
impaired over the dorsum of her right foot.

Investigations:

CXR is normal.

Hb 10.9 g/dL

MCV 90 fl

WBC 23 x 10 9 /I

Eosinophils 12%

ANCA negative

What is the likely diagnosis?

1- Polyarteritis nodosa

2- Churg Strauss syndrome

3- SLE

4- Allergic broncho pulmonary aspergillosis

5- Takayasu's arteritis

Answer & Comments

Answer: 2- Churg Strauss syndrome

The combination of mononeuritis multiplex,
asthma, eosinophilia.

The American College of Rheumatology (ACR)
has proposed 6 criteria for diagnosis of Churg
Strauss syndrome. The presence of 4 or more
criteria yields a sensitivity of 85% and a
specificity of 99.7%.

Vasculitic rash on the skin of a patient with
Churg Strauss syndrome

^ [ Q: 156 ] MRCPass - Rheumatology

/ -—

# A 40 year old man has generalised

joint pains and stiffness, particularly in the

knees. He also has sore, dry eyes and difficulty

tolerating contact lenses. On examination

there are no joint swellings or effusions. His

ESR is 80 mm/hour, Rheumatoid Factor

positive with a titre of 1/1024.

Which of the following is likely?

1- Positive antibodies to Ro and La antigens

2- Positive anti SCL-70 antibody

3- Positive anti mitochondrial antibodies

4- Positive anti-Sm antibodies

5- Positive ANCA

These criteria are

(1) asthma (w heezing, expiratory rhonchi)

(2) eosinophilia of more than 10% in
peripheral blood

(3) paranasal sinusitis

(4) pulmonary infiltrates (may be transient)

(5) histological proof of vasculitis with
extravascular eosinophils

(6) mononeuritis multiplex or polyneuropathy

Answer & Comments

Answer: 1- Positive antibodies to Ro and La
antigens

Ro is also known as anti ssA and La is known
as anti ssB antibody, both are diagnostic tests
for Sjogrens. The history of dry eyes
(keratoconjunctivitis sicca) and joint pains
with strongly positive RhF goes with Sjogrens.

*1 J

[ Q: 157 ] MRCPass - Rheumatology

A 45 year old man has recurrent

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sinusitis and haemoptysis. He also has
haematuria and mild renal impairment.

Tests are sent for suspected Wegener's
granulomatosis.

Which one of the following tests has greatest
specificity for Wegener's gronulomotosis?

1- Anti glomerular basement antibody

2- pANCA positive antibodies proteinase 3

3- pANCA positive antibodies myeloperoxidase

4- cANCA positive antibodies proteinase 3

5- cANCA positive antibodies myeloperoxidase

Answer & Comments

Answer: 4- CANCA positive antibodies
proteinase 3

On immunofluoresecnce, if ANCA are present,
the staining pattern may be cytoplasmic
(cANCA) or perinuclear (pANCA). Typical
antigen specificity includes c ANCA proteinase
3 which is more common in Wegener's
granulomatosis, p ANCA myeloperoxidase is
more common in polyarteritis nodosa.

^ [ Q: 158 ] MRCPass - Rheumatology

m A lady with w hiplash injury 5 years
ago presents with pains in the neck and
shoulder. They were not relieved by 12 co-
codamols a day.

What should be done next?

1- Amitryptilline

2- NSAIDs

3- Physiotherapy

4- Morphine

5- Gabapentin

Answer & Comments

Answer: 3- Physiotherapy

Whiplash injuries and radiculopathies causing
back pains can be difficult to treat with

medications. Physiotherapy has an important
role for symptom relief in combination with
analgesia.

[ Q: 159 ] MRCPass - Rheumatology

A 45 year old man presents with a
week history of a painful right leg. He has had
previous episodes of erythema nodosum,
recurrent oral and scrotal ulceration.
Examination reveals a diffusely swollen left
leg.

What is the likely cause of his swollen leg?

1- Baker's cyst

2- Gonococcal arthritis

3- Reactive arthritis

4- Deep vein thrombosis

5- Cellulitis

Answer & Comments

Answer: 4- Deep vein thrombosis

The overall diagnosis is Behcet's syndrome.
There is a thrombotic tendency, hence the
likely cause of a DVT.

[ Q: 160 ] MRCPass - Rheumatology

A 45 year old woman presents with
pain in the wrist. The pain is centred over the
radial styloid and is increased by abduction of
the thumb against resistance.

What is the most likely diagnosis?

1- Carpal tunnel syndrome

2- Rheumatoid arthritis

3- De Quervain's tenosynovitis

4- Osteoarthritis

5- Adductor pollicis synovitis

Answer & Comments

Answer: 3- De Quervain's tenosynovitis

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The pain in the thumb on resisted abduction is
typical of De Quervain's.

2- Rituximab

3- Methotrexate

De Quervain's disease occurs more frequently
in w omen. The age group usually affected is
30 to 50 year olds.

4- Vincristine

5- Hydroxychloroquine

The history often is of unaccustomed or
excessive activity such as rose pruning. The
patient complains of pain on the radial side of
the wrist. Abduction of the thumb against
resistance is painful. Finkelstein's test is
positive. This is performed with the thumb
flexed across the palm of the hand, asking the
patient to move the wrist into flexion and
ulnar deviation.

This stresses the tendons of abductor pollicis
longus and extensor pollicis brevis and
reproduces the pain of de Quervain's
tenosynovitis.

Finkelstein's test

[ Q: 161 ] MRCPass - Rheumatology

A 43 year rheumatoid arthritis was
investigated routinely and had the following
results:

Haemoglobin 11.2 g/dL
Platelets 385 x 10 9 /L
White Cell Count 8.2 x 10 9 /L
MCV110 fL

Which drug is she likely to hove been on?

1- Aspirin

Answer & Comments

Answer: 3- Methotrexate

Methotrexate is associated with bone marrow
suppression, and can lead to pancytopenia or
a megaloblastic anaemia, especially if folate
treatment is not given as well.

[ Q: 162 ] MRCPass - Rheumatology

A 75 year old woman has recently
been commenced on alendronate for
osteoporosis.

Whot is the mechanism of action of
alendronate?

1- Increases osteoblast activity

2- Inhibits osteoclast activity

3- Increases vitamin D absorption

4- Causes hypercalcaemia

5- Increases the action of oestrogen on bone

Answer & Comments

Answer: 2- Inhibits osteoclast activity

Alendronate is a bisphosphonate which can
increase bone mineralisation by inhibiting
osteoclastic activity.

[ Q: 163 ] MRCPass - Rheumatology

An 75 year old man presents with
bilaterally painful knees. He has bilateral
reduced knee movements and crepitus. X ray
shows sclerosis, osteophytes and loss of joint
space.

Which one of the following is the most
appropriate initial treatment?

1- Ibuprofen

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2- Ibuprofen and lansoprazole

3- Paracetamol

4- Codeine phosphate

5- Celecoxib

Answer & Comments

Answer: 3- Paracetamol

The principle goal of systemic therapy in
osteoarthritis is to provide effective pain relief
with least associated toxicity. Paracetamol is
the recommended initial therapy, especially in
the elderly due to possible gastrointestinal
upset.

^ [ Q: 164 ] MRCPass - Rheumatology

# A 35 year old woman recently
arrived in the UK from Ghana. She complains
of neck pain with pins and needles affecting
the right arm associated with a weak grip.

Examination reveals tenderness over the
cervical spine. X rays of the cervical spine
shownarrow ing of the C3/4 and C4/5 joint
space and partial collapse of C4.

Investigations show :

Hb 9.5 g/dl

WCC 11.1

platlets 520

ESR 120 mm in the first hour
CRP 250 g/l

Calcium 2.21 micromol/l
Albumin 32 g/l

alkaline phosphatase 210 units/I
phosphate 0.8 micromol/l.

What is the most likely diagnosis?

1- Potts disease

2- Osteoporosis

3- Multiple myeloma

4- Ankylosing spondylitis

5- Syringomyelia

Answer & Comments

Answer: 1- Potts disease

Pott's disease is tuberculous infection of the
spine with associated collapse of the vetebral
body. The infection spreads from tw o
adjacent vertebrae into the adjoining disc
space. If only one vertebra is affected, the disc
is normal, but if tw o are involved the
intervertebral disc, which is avascular,
collapses.

Signs and symptoms include: Localised back
pain, Paravertebral swelling, Neurological
signs including paraplegia.

Drug treatment (antituberculous drugs) is
generally sufficient for Pott's disease, with
spinal immobilisation if required. Surgery is
required if there is spinal deformity or
neurological signs of spinal cord compression.

Potts disease on an MRI

[ Q: 165 ] MRCPass - Rheumatology
A 35 year old woman presents with

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tight skin over her hands with Raynaud's
phenomenon. She has ulceration of the
fingertips and associated small white deposits.
She has noted increasing breathlessness over
the past few years. Renal function is mildly
impaired.

What is the likely diagnosis?

1- SLE

2- Ataxia telangiectasia

3- Polymyositis

4- Limited cutaneous scleroderma

5- Diffuse cutaneous scleroderma

Answer & Comments

Answer: 4- Limited cutaneous scleroderma

Limited cutaneous scleroderma is also known
as CREST syndrome (calcinosis, Raynaud's,
(o)esophageal dysfunction, sclerodactyly, and
telangiectasia). 'Limited' refers to the extent
of skin involvement limited to the forearms
and face. They generally develop pulmonary
hypertension rather than pulmonary fibrosis,
leading tow ards breathlessness.

Tight thickened skin (sclerodactyly) seen in

Scleroderma

[ Q: 166 ] MRCPass - Rheumatology

A 70 year old woman complains of
pain at the base of her right thumb. There is
tenderness and swelling of right first
carpometacarpal joint.

What is the likely diagnosis?

1- De Quervain's tenosynovitis

2- Rheumatoid nodule

3- Osteoarthritis

4- Psoriatic arthropathy

5- Reiter's syndrome

Answer & Comments

Answer: 3- Osteoarthritis

Osteoarthritis of the 1st carpometacarpal joint
is common. Swelling is usually bony hard due
osteophyte formation. PIP joint nodes are
known as Bouchard's and DIP joint nodes are
known as Heberden's nodes.

Arthritis of
the thumb

(carpal-metacarpal joi

[ Q: 167 ] MRCPass - Rheumatology

* A 70 year old patient has a set of
investigations due to lethargy. She complains
of polyuria and generalised back pains. Upon
investigation, she has the following results:

Hb 8 g/dl

MCV 100 fl

Platelets 190 x 10 9 /L

total protein 90 g/l (60-76) gm%

Albumin 35 (37-49) g/l

calcium 2.9 (2.25-2.7) mmol/l

phosphate 0.75 (0.8-8) pmol/l

What is the appropriate next investigation?

1- Complete liver function tests

2- Urinary albumin

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3- Plasma electrophoresis

4- 24 hour urine protein

5- Uric acid

Answer & Comments

Answer: 3- Plasma electrophoresis

The patient has multiple myeloma as indicated
by hypercalcaemia, polyuria and bone pains.

[ Q: 168 ] MRCPass - Rheumatology

A 72 year old lady has severe pain in
the left knee and right hand. An X ray of the
hand shows osteophytes and an X ray of the
knee was normal. On examination, she has
limited left hip flexion.

Whot should be the next investigation for the
knee?

1- MRI of the knee

echocardiography shows complete heart
block.

Which one of the following maternal
autoantibodies is likely to be present?

1- Ant

2- Ant

3- Ant

4- Ant

5- Ant

Ro (SSA)
dsDNA
La (SSB)
Jo 1

centromere

Answer & Comments

Answer: 1- Anti Ro (SSA)

AntiRo antibody is associated with congenital
complete heart block. When congenital
complete heart block occurs, SS-A antibodies
are almost alw ays present in maternal and
fetal serum (maternal anti-Ro(SS-A) antibody
crosses the placenta).

2- Bone scan

3- Arthroscopy of the knee

4- CT scan of the knee

5- Ultrasound of the knee

Answer & Comments

Answer: 1- MRI of the knee

The patient's presentation suggests
osteoarthritis, but an MRI would be helpful to
exclude other pathology as well as confirm
osteoarthritis in the context of a normal knee
X ray. The MRI is useful for assessing the state
of the cruciate ligaments and the joint
cartilage as well as avascular necrosis.
Arthroscopy is helpful but invasive in this
instance.

^ [ Q: 169 ] MRCPass - Rheumatology

/ -

# A 28 year old patient with systemic

lupus erythematosus attends the obstetric
clinic at 25 weeks into her pregnancy. The
foetal heart rate is 45 beats per minute. Foetal

[ Q: 170 ] MRCPass - Rheumatology

A 34 year old lady with systemic
sclerosis complained of lethargy. Her blood
pressure was 185/90 mmHg.

Fundoscopy showed cotton wool spots.

Investigations showed that her U+Es were:

sodium 135 mmol/I

potassium 4.5 mmol/I

urea 12 mmol/l

creatinine 225 pmol/l

What is the treatment of choice for this
patient?

1- Oral Captopril

2- IV Prostacyclin

3- IV Labetalol

4- IV Sodium nitroprusside

5- Oral Atenolol

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Answer & Comments

Answer: 1- Oral Captopril

Answer & Comments

Answer: 2- Psoriasis

A major complication of scleroderma is renal
crisis. This is characterised by abrupt onset of
severe hypertension, usually retinopathy,
together with rapid deterioration of renal
function and heart failure.

Hypertension should be treated with an ACE
inhibitor. This is because the underlying
pathology causing hypertension is angiotensin
ll-induced vasoconstriction, and trials have
shown ACE -inhibitors to have the best
antihypertensive efficacy and improved
survival.

The aim is to reduce pressure gradually, as an
abrupt fall can lead to cerebral ischemia
/infarctions (as in any accelerated
hypertension), and may cause decreased renal
perfusion as well as acute tubular necrosis.
Calcium channel blockers may be added to
ACE inhibitors. Parenteral antihypertensive
agents (such as intravenous nitroprusside or
labetalol) should be avoided as they cause
abrupt blood pressure drops.

[ Q: 171 ] MRCPass - Rheumatology

A 45 year woman presents with an 8
month history of joint pains and stiffness of
the hands and feet.

Examination reveals a synovitis of the distal
interphalangeal joints, left index finger, right
wrist and ankle joints.

Nail pitting was noticed. Her ESR was 20
mm/hr.

The diagnosis is psoriatic arthritis. Psoriatic
arthritis is subclassified according to different
patterns of arthritis: asymmetrical

oligoarthritis, symmetric polyarthritis,
spondyloarthropathy and arthritis mutilans. In
about 20% of patients there is a chronic,
progressive, deforming arthropathy in an
asymmetrical pattern, including distal
interphalangeal joint involvement.

Psoriatic Arthropathy - note onycholysis on

the nails

^ [ Q: 172 ] MRCPass - Rheumatology

* A 16 year old girl presents with
widespread palpable purpura over legs and
buttocks. She has abdominal pains and is
noted to have blood and protein on urine
dipstick.

What is the most likely diagnosis?

1- Juvenile dermatomyositis

2- Juvenile chronic arthritis

3- Henoch Schonlein purpura

4- Rheumatoid arthritis

Which one of following conditions is
associated with the pattern of joint
involvement?

1- SLE

2- Psoriasis

3- Rheumatoid arthritis

4- Septic arthritis

5- Reactive arthritis

5- HUS-TTP

Answer & Comments

Answer: 3- Henoch Schonlein purpura

Henoch-Schonlein purpura (HSP) is a systemic
vasculitis mostly seen in children. It is a
multisystem disorder involving the skin, joints,
gastrointestinal and renal tracts.

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Aetiology is unknown, but the syndrome is
often preceded by infections such as Group A
beta hemolytic streptococcal respiratory tract
infection, Campylobacter jejuni, Mycoplasma
pneumoniae and viruses such as varicella,
hepatitis B, Epstein-Barr virus, and parvovirus
B19.

Pathology is due to intravascular deposition of
IgA immune complexes with activation of
complement and leucocyte infiltration.
Patients often present with a purpuric rash
usually involving the buttocks and lower limbs,
arthralgia and joint swelling, severe colicky
abdominal pain and tenderness caused by
vasculitis-induced thrombosis in the gut.

Renal involvement commonly presents as
microscopic haematuria and proteinaemia.
The most serious long-term

complication from HSP is progressive renal

failure.

[ Q: 173 ] MRCPass - Rheumatology

5- Ankylosing spondylitis

Answer & Comments

Answer: 5- Ankylosing spondylitis

Ankylosing spondylitis is a seronegative
arthropathy associated with HLAB27
genotype. It leads to increased stiffness and
fusion of the vertebrae causing a bamboo
spine. Typically, the sacroiliac joints and hip
joints are affected, but thoracic and cervical
spines are eventually affected as well.

There is a list of associations mostly starting
with A. These are anterior uveitis/iritis, aortic
regurgitation, aortic aneurysm, apical fibrosis,
aspergillosis infection, amyloidosis and
archilles tendinitis.

In bamboo spine, there is fusion of the
vertebral bodies and squaring of the
vertebrae. One also expects syndesmophytes
(thin vertical dense spicules bridging the
vertebral bodies), Romano lesions (erosion at
the corner of vertebral bodies) and
enthesopathy (ligament or tendon
calcification).

# A 45 year old man has difficulty
bending touching his toes w hen bending over.
He has lower back pain, stiffness in the
thoracic region and reduced chest expansion.
His lower spine X-ray is shown above. He has
negative rheumatoid factor, and a HLA-B27
genotype.

What is the diagnosis?

Bamboo Spine

1- Paget's disease

2- Osteoarthritis

3- Marble bone disease

4- Marfan's syndrome

[ Q: 174 ] MRCPass - Rheumatology

A 35 year old woman presents with
red scaly plaques on her cheeks and her
forehead. On closer examination, there was

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plugging of some hair follicles and atrophy of
the skin.

Whot is the likely diagnosis?

1- Drug induced lupus

2- Psoriasis

3- Discoid lupus

4- Sarcoidosis

5- Lupus pernio

Answer & Comments

Answer: 3- Discoid lupus

The diagnosis is discoid lupus erythematosus.
Lesions are discrete plaques, often
erythematous, scaly, with extension into hair
follicles. These lesions can occur on the face,
scalp, in the pinnae, behind the ears or on the
neck. There can also be active indurated
erythema and central atrophic scarring.

Discoid lupus

Answer & Comments

Answer: 3- Infliximab

The Anti-TNF drugs are infliximab and
adalimumab. The criteria for treatment with
these drugs are that patients who have been
treated with at least tw o DMARDs (disease¬
modifying drugs) continue to have active
rheumatoid arthritis.

Examples of the DMARDs are: gold injections,
sulphasalazine, hydroxychloroquine,

leflunomide, cyclosporin, azathioprine and
methotrexate [One of the tw o must be
methotrexate].

[ Q: 176 ] MRCPass - Rheumatology

A 45 year old woman presents with a
year's history of Raynaud's phenomenon,
dyspepsia and joint pains. On examination,
she has sclerodactyly and synovitis of small
joints of her hands. Her ESR is 60 mm/hr (<10)
but Rheumatoid factor and Antinuclear
Antibody are both negative.

What other clinical feature is likely in this
patient?

1- Splinter haemorrhages

2- Erythema marginatum

3- Butterfly rash

4- Anterior uveitis

[ Q: 175 ] MRCPass - Rheumatology

A 50 year old patient with active
rheumatoid arthritis has failed treatment with
gold, methotrexate, hydroxychloroquine and
sulphasalasine. She has ongoing joint pains
and erosive damage.

What is the most appropriate treatment ?

1- High dose prednisolone

2- COX2 inhibitors

3- Infliximab

4- Ciclosporin

5- Azathioprine

5- Small bowel hypomotility

Answer & Comments

Answer: 5- Small bowel hypomotility

This woman features of a mixed connective
tissue disorder such as CREST/systemic
sclerosis, sclerodactyly, Raynaud's, dyspepsia
and arthralgia. The other likely development
would be malabsorption which is associated
with hypomotility of the small bow el.

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^ [ Q: 177 ] MRCPass - Rheumatology

fi -

# A 60 year old man is on treatment
for chronic heart failure with diuretics. He has
preivous history of athma. He presents with
sudden onset of pain and swelling of the
metatarso-phalangeal joint of his right big toe.
Aspiration of the joint demonstrates crystals
of monosodium urate.

What is the recommended treatment?

1- Aspirin

2- Colchicine

3- Non-steroidal anti-inflammatory drugs

4- Cyclooxygenase 2 inhibitor

5- Allopurinol

Answer & Comments

Answer: 2- Colchicine

progress to other parts. It is due to autonomic
nervous system dysfuction. Symptoms of
extreme pain and burning can occur.
Analgesics are often unhelpful.

Flushing, shiny and atrophied skin on the left
leg indicating reflex sympathetic dystrophy

In this particular patient, colchicine is the best
option. In acute gout, either colchicine or
NSAIDs can be used. How ever, asthma
contraindicates NSAIDs.

[ Q: 178 ] MRCPass - Rheumatology

A 35 year old man is renovating his
apartment w hen he slams a door against his
foot. He develops swelling, erythema and pain
in all the digits of his foot. He has an ESR of
20mm/hour and a temperature of 36°C.

What is the likely diagnosis?

1- Porphyria

2- Cellulitis

3- Gout

4- Raynaud's phenomenon

5- Reflex sympathetic dystrophy

Answer & Comments

Answer: 5- Reflex sympathetic dystrophy

Reflex sympathetic dystrophy occurs following
trauma to an injured part of the body, and can

^ [ Q: 179 ] MRCPass - Rheumatology

/ -

m A 42 year old lady has tightening of

the skin around her hands and mouth. She has
several telangiectasia on her hands, and
complains of severe cold hands in winter. She
was noticed to be pale.

Investigations show :

Hb 4.5 g/dl

MCV 105 fl

WCC 6 x 10 9 /L

platelets 230 x 10 9 /L

Iron 22 (14-29) pmol/l

Ferritin 155 (15-200) pmol/l

total iron binding capacity 50 (45-72) umol/l

Folate 11 (3-20) ?g/l

Vitamin Bi 2 - 85 (120-700 pmol/l)
What is the likely cause of anaemia?

1- Pernicious anaemia

2- Secondary folate deficiency

3- Celiac disease

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4- Methotrexate

5- Bacterial overgrowth

Answer & Comments

Answer: 5- Bacterial overgrowth

Scleroderma can cause folate deficiency due
to malabsorption. However, in this case, the
folate levels are normal and there is B12
deficiency.

B12 deficiency can occur in conditions where
there is bacteria overgrowth in the small
intestine (blind loop syndromes) such as
jejunal diverticulosis, Crohns disease, fistulas
and scleroderma. The anaerobic organisms
metabolise vitamin Bn and impair absorption.
When systemic sclerosis (SSc) involves the
small intestine, normal peristaltic movements
are lost and motility is impaired leading to
stasis and dilatation.

[ Q: 180 ] MRCPass - Rheumatology

A 55 year old man develops sudden
onset severe pain in his right big toe.

On examination he has swelling of the
metacarpophalangeal joint of his right hallux.
The surround skin is erythematous. It is tender
to touch. Initial investigations reveal a raised
white cell, count and an elevated CRP.

What should be done to confirm the
diagnosis?

1- MRI of the toe

2- Serum uric acid

3- Serum rheumatoid

4- Joint fluid aspirate for microscopy

5- Serum pyrophosphate levels

Answer & Comments

Answer: 4- Joint fluid aspirate for microscopy

The likely diagnosis is acute gout. The serum
inflammatory markers are raised, but uric acid
levels may be normal.

Joint fluid aspirate best test. Polarised light
microscopy shows strongly birefringent
(negative sign) needle-shaped crystals.

Acute Gout involving the left foot

[ Q: 181 ] MRCPass - Rheumatology

A 80 year old man developed acute
monoarthritis of his right ankle following an
admission with congestive cardiac failure. He
mentioned that he had ankle oedema and had
recently been prescribed frusemide by the GP.

What is the likely diagnosis?

1- Rheumatoid arthritis

2- Gout

3- Pseudogout

4- Osteoarthritis

5- Septic arthritis

Answer & Comments

Answer: 2- Gout

Gout can be precipitated by diuretics, e.g.
frusemide.

[ Q: 182 ] MRCPass - Rheumatology

A 45 year old has a past history of
systemic sclerosis. She now has headaches
and blurred vision. On examination, she has a
blood pressure of 220/100 mmHg and there is
evidence of bilateral papilloedema.

Which of the following medications should be
prescribed?

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1- Oral hydrochlorothiazide

2- Oral Lisinopril

3- Sublingual Nimodipine

4- IV Sodium Nitroprusside

5- IV Labetolol

Answer & Comments

Answer: 2- Oral Lisinopril

A major complication of scleroderma is renal
crisis which is characterised by abrupt onset of
severe hypertension. The hypertension almost
alw ays is severe with a diastolic BP over 100
mmHg in 90% of patients. There is associated
hypertensive retinopathy in about 85% of
patients. ACE inhibitors are first line, with an
aim to reduce the blood pressure gradually.

[ Q: 183 ] MRCPass - Rheumatology

A 50 year old man presents an acute
monoarthritis of left knee. Gout is confirmed
following joint aspiration and examination of
fluid under polarised light microscopy. He had
also underwent endoscopy 3 weeks earlier
because of indigestion this confirmed a
duodenal ulcer.

Which one of the following is the best
treatment for the patient?

1- Allopurinol

2- Intraarticular corticosteroid injection

3- Indomethacin and Lansoprazole

4- Celecoxib and Lansoprazole

5- Indomethacin and Misoprostol

Answer & Comments

Answer: 2- Intraarticular corticosteroid

injection

All non-steroidals including Cox II selective
inhibitors are relatively contraindicated in the
presence of active ulceration. In a large joint

such as the knee, the safest option would be
inject corticosteroid into the joint.

[ Q: 184 ] MRCPass - Rheumatology

A 62 year old man has a 5 week
history of pain and swelling affecting left knee,
both ankles and his right wrist.

He has lost 6 kg in weight.

His investigations show :

WCC 14.1 x 10 9 /L

Hb 10.3 x 10 9 /L

MCV 72 fl

pit 510 x 10 9 /L

ESR 63 mm in the first hour

CRP 21 g/l

CK 120 iu

Rh F1/80

ANA negative

ENA negative

XR of hands and feet normal.

What is the most likely diagnosis?

1- Paraneoplastic syndrome

2- Osteoarthritis

3- Polymyositis

4- Scleroderma

5- Behcet's syndrome

Answer & Comments

Answer: 1- Paraneoplastic syndrome

The CK is not significantly raised. Weight loss
and anaemia suggest underlying malignancy.
Paraneoplastic syndrome can present with an
assymetrical arthralgia which more commonly
affects the lower limbs. False positive
rheumatoid factor can occur but should be of
low titre.

[ Q: 185 ] MRCPass - Rheumatology

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A 45 year old lady has had long standing
arthritis of her hands. Her has hand X-rays
done.

Which of the following X ray changes suggests
rheumatoid arthritis instead of a seronegative
arthropathy?

1- Osteosclerosis

2- Osteophytes

3- Osteoporotic changes

4- Periarticular erosions

5- Loss of joint space

Answer & Comments

Answer: 4- Periarticular erosions

Osteophytes and loss of joint space are
commonly found in osteoarthritis, although
they can also be found in rheumatoid arthritis.
Periarticular erosions are most suggestive of
rheumatoid arthritis.

[ Q: 186 ] MRCPass - Rheumatology

A 76 year old woman presents with
weakness of his hand. On examination there
was tenderness, crepitus and bony swellings
over the base of the first metacarpal and
wasting of the right thenar eminence.

Investigations reveal an ESR of 25 mm/lst hr,
a CRP of lOmg/L, a Urate concentration of
0.42 (0.19-0.36). Her Rheumatoid factor was

60 IU/L (<30). An xray of the right hand
showed a loss of joint space, periarticular
sclerosis and osteophytes of the first
carpometacarpal joint.

What is the likely diagnosis?

1- Osteoarthritis

2- DeQuervain's tenosynovitis

3- Pseudogout

4- Gout

5- Rheumatoid arthritis

Answer & Comments

Answer: 1- Osteoarthritis

The patient has clinical and radiological
features consistent with osteoarthritis (OA) of
the 1st right carpometacarpal (CMC) joint. The
condition is characterised by joint pain,
crepitus and stiffness after movement. Joint
swellings are bony in nature (Bouchard's and
Heberden's nodes), unlike boggy swellings
which occurs in inflammatory arthritis. This
patient's inflammatory markers are mildly
raised only, making an inflammatory arthritis
unlikely.

[ Q: 187 ] MRCPass - Rheumatology

A 70 year old man presents with
severe back pains. An His total serum protein
is 85 g/l with an albumin of 41 g/l.

A chest X ray shows several lucencies in
vertebral bodies. A sternal bone marrow
aspirate obtains a dark red jellylike material in
the syringe.

The smear of aspirate is likely to show which
prominent features ?

1- Macrophages

2- Osteoblasts

3- Plasma cells

4- Pneumocytes

5- Osteosarcoma

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Answer & Comments

Answer: 3- Plasma cells

The diagnosis is multiple myeloma. The bone
marrow needle is likely to be in a lytic lesion
filled with plasma cells. His serum globulins
are high from the monoclonal gammopathy.

^ [ Q: 189 ] MRCPass - Rheumatology

fl -

# A 25 year old Turkish man was noted
by ophthalmologists to have a posterior
uveitis requiring high dose

immunosuppression. He has a history of
recurrent mouth ulcers and painful ulcers on
the scrotum.

A plasma cell

Whot is the likely diagnosis?

1- Behcet's syndrome

2- Reiter's syndrome

3- Ankylosing spondylitis

4- Takayasu's arteritis

5- Giant cell arteritis

Answer & Comments

Answer: 1- Behcet's syndrome

[ Q: 188 ] MRCPass - Rheumatology

A 75 year old man presents with
bilateral hip pains. Investigations reveal:

Corrected calcium 2.5 (2.2 - 2.6) mmol/I

ESR 22 mm/lst hr

Alkaline phosphatase 800 iu/L (50 - 100)

gammaGT 22 iu/L

What is the likely diagnosis?

1- Osteoporosis

2- Osteomalacia

3- Paget's disease of the pelvis

4- Polymyalgia rheumatica

5- Multiple myeloma

Behcet's syndrome is classically characterized
as a triad of symptoms that include recurring
crops of mouth ulcers (called apthous ulcers),
genital ulcers, and uveitis. The ulcers are
usually painful. The disease is more frequent
and severe in patients from the Eastern
Mediterranean and Asia than those of
European descent.

Eye manifestations may result in blindness. In
addition, iritis, retinal vessel occlusions and
optic neuritis can be found. Hypopyon uveitis
(pus in the anterior chamber of the eye),
which is considered the hallmark of Behget's
disease, is in fact a rare manifestation. The
arthritis of Behget's disease is usually
intermittent, self-limited, not deforming and
localized to the knees and ankles.

Answer & Comments

Answer: 3- Paget's disease of the pelvis

This elderly patient presenting with bone
pains has significantly elevated alkaline
phosphatase but normal calcium
concentrations suggesting a diagnosis of
Paget's.

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[ Q: 190 ] MRCPass - Rheumatology

A 70 year old woman has polydipsia
and polyuria for 3 months. She also complains
of loin pains. She has not been on any
medication.

Investigations reveal:

serum urea 6 (2.5-7.5) pmol/l

serum creatinine 80 (60-110)pmol/l

serum albumin 38 g/L (37-49)

serum total calcium 3.1 (2.2-2.6)

Whot is the likely couse of the
hypercoicoemio?

1- Multiple myeloma

2- Sarcoidosis

3- Paget's disease

4- Primary hyperparathyroidism

5- Vitamin D toxicity

Answer & Comments

Answer: 4- Primary hyperparathyroidism

Primary hyperparathyroidism is caused by an
overproduction of PTH.

Excess PTH results in an increase in bone
breakdown by means of osteoclastic
resorption with subsequent fibrous
replacement and reactive osteoblastic activity.
Historically, in classic primary
hyperparathyroidism, nephrolithiasis was
noted in 50% of patients, and it was the most
common clinical presentation of the disease.
Additional manifestations of primary
hyperparathyroidism include pancreatitis,
peptic ulcer disease, and cardiovascular
abnormalities.

[ Q: 191 ] MRCPass - Rheumatology

A 42 year old lady presents with
backache. Her blood results are as follow s:

Hb llg/dL

Ca 1.9 mmol/L

Phosphate 0.8 mmol/L
Alkaline phosphatase 220 U/L
Albumin 38 g/L
Urea 7 mmol/L
Sodium 142 mmol/L
Potassium 3.9 mmol/L
Whot is the diagnosis?

1- Osteoporosis

2- Paget's disease

3- Osteomalacia

4- X linked hypophosphataemic rickets

5- Hypoparathyoroidism

Answer & Comments

Answer: 3- Osteomalacia

The patient has osteomalacia with secondary
hyperparathyroidism causing low phosphate
levels. Osteomalacia is due to vitamin D
deficiency which could be due to
malabsorption or dietary defiency, or
renal/liver disease.

[ Q: 192 ] MRCPass - Rheumatology

A 32 year old woman has a deep vein
thrombosis. Her previous history included
investigations for miscarriages.

Investigations revealed: Haemoglobin 11.9
g/dl, White cell count 4 x 10 9 /L, Platelet count
30 x 10 9 /L.

Which of these ore likely to be obnormol?

1- Homocysteine level

2- ANCA

3- Protein C

4- Antiphospholipid antibody

5- Coomb's test

Answer & Comments

Answer: 4- Antiphospholipid antibody

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Antiphospholipid syndrome leads to venous
and arterial thrombosis, livedo reticularis,
splinter hemorrhages, leg ulcer, multi-infarct
dementia, chorea, Thrmobocytopenia (40% of
patients), hemolytic anemia and late term
miscarriages.

[ Q: 193 ] MRCPass - Rheumatology

A 35 year old man presents with
acute stiffness swelling of his knees and
ankles, a painful rash on his legs. The ESR was
100 mm/hour. Chest Xray showed hilar
lymphadenopathy bilaterally.

What is the likely progression of the
arthralgia?

1- Chronic arthritis

2- Septic arthritis

3- Improvement only with steroids

4- Spontaneous improvement

5- Permanent joint destruction

Answer & Comments

Answer: 4- Spontaneous improvement

The description typical of acute sarcoidosis -
erythema nodosum, oligoarthropathy and
hilar lymphadenopathy. This usually has a
good prognosis, with resolution over 6-8
weeks.

[ Q: 194 ] MRCPass - Rheumatology

A 75 year old lady presents with back
pains. Lateral spine X-rays and pelvic x-rays
show osteopenia. A serum corrected calcium
is 1.8 mmol/l and phosphate is 0.6 mmol/I.
Alkaline phosphatase is 360 U/l.

Which diagnosis is most likely?

1- Myeloma

2- Osteoporosis

3- Osteomalacia

4- Paget's disease

5- Ankylosing spondylitis

Answer & Comments

Answer: 3- Osteomalacia

Osteomalacia is more likely than osteoporosis
due to the low calcium, low phosphate and
raised alkaline phosphatse. The condition is
caused by low vitamin D levels.

Alkaline phosphatase is raised w hen there is
increased osteoblastic activity, conditions it
may be raised in:

Paget's disease

osteomalacia and rickets

renal osteodystrophy

bone metastases

[ Q: 195 ] MRCPass - Rheumatology

A 22 year old lady has a sw inging
fever, half a stone weight loss over 2 months,
generalised myalgia, polyarthralgia affecting
wrists, knees, ankles, elbows
metacarpophalangeal joints and a sore throat.

Investigations show : Hb 9.5g/l, MCV 85 fl, ESR
92 mm in first hour, CRP 45 g/l, serum ferritin
1600 mg/dl, RF negative, ANA negative, ENA
negative, ASO titre <200iu.

What is the likely diagnosis?

1- Rheumatoid arthritis

2- Ankylosing spondylitis

3- Adult onset Still's disease

4- Inclusion body myositis

5- Polymyositis

Answer & Comments

Answer: 3- Adult onset Still's disease

Adult Onset Still's Disease (AOSD) is an acute
febrile illness in young adults. It usually affects
multiple organs, but is a diagnosis of
exclusion.

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Clinical features include a high fever,
arthralgia and arthritis, phayngitis, typical rash
(evanescent salmon-colored, macular or
maculopapular eruption), lymphadenopathy,
and serositis. Chronic arthritis and
constitutional symptoms are common.

The triad of fever, rash, and arthralgia are
often absent during the first month of the
illness. The usual joints affected are wrists,
knees, and ankles in descending order.

Tw o thirds of cases experience polyarticular
arthritis and one third have monoarticular
symptoms.

Approximately 1/3 of patients have chronic
persistent disease with progressive joint
damage.

[ Q: 196 ] MRCPass - Rheumatology

A 65 year old woman has a swollen,
erythematous knee joint. Aspiration of the
joint was performed. Microscopy showed
positively birefringent crystals.

^ [ Q: 197 ] MRCPass - Rheumatology

tl -

* A 45 year old woman presents with
claudication in her lower limbs. She is noted to
have absent left arm pulses.

The previous year she had a small hemispheric
cerebrovascular infarct.

What is the likely diagnosis?

1- Giant cell arteritis

2- Takayasu's arteritis

3- Familial hypercholesterolaemia

4- Coarctation of the aorta

5- Anti phospholipid syndrome

Answer & Comments

Answer: 2- Takayasu's arteritis

Takayasu's arteritis is a large vessel vasculitis
of unknown origin. The vasculitic process
involves structures such as the aorta, great
vessels, the sclera and the cardiac conduction
tissues.

What are the crystals composed of?

1- Calcium carbonate

2- Magnesium sulphate

3- Urate

4- Calcium pyrophosphate

5- Aminolaevulinic acid

Women are affected more than men, usually
in the second and third decades of life.
Presentation is often with symptoms such as
fever, weight loss, night sweats and
arthralgias. Symptoms related to ischaemia
may include ischaemic stroke, visual
disturbances and claudication.

Answer & Comments

Answer: 4- Calcium pyrophosphate

Pseudogout is caused by the deposition of
calcium pyrophosphate deposition rather than
the deposition of uric acid derivatives that
cause gout. Also, in pseudogout, synovial fluid
samples obtained with aspiration have
positive birefringence. This finding is in direct
contrast to the negative birefringence in gout.

[ Q: 198 ] MRCPass - Rheumatology

A 70 year old man develops
weakness of the shoulders and around the
hips over a 6 month period. He has also
noticed weak finger flexors. He complained of
difficulty sw allow ing liquids. There is no
other significant past medical history. He
smokes 15 cigarettes a day and drinks a bottle
of w ine at the weekend. A creatinine kinase
level comes back at 120 U/l.

A muscle biopsy sample shows myopathic
changes. There are also inflammatory

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infiltrates and intracytoplasmic vacuoles
present.

What is the likely diagnosis?

1- Polymyositis

2- Fibromyalgia

3- Polymyalgia rheumatica

4- Dermatomyositis

5- Inclusion body myositis

Answer & Comments

Answer: 5- Inclusion body myositis

The diagnosis is inclusion body myositis (IBM).
This is an inflammatory condition affecting
patients over the age of 50. Proximal muscles
in the upper and lower limbs, and finger
flexors are predominantly involved. The onset
of muscle weakness in IBM is generally
gradual (over months or years).Dysphagia is
common, occurring in 40-66% of patients.

IBM occurs more frequently in men than w
omen. CK may be normal. A muscle biopsy
usually shows intracytoplasmic inclusions and
also inflammatory infiltrates.

Thigh atrophy seen in inclusion body myositis

Inclusion bodies and inflammatory infiltrates

(arrows)

[ Q: 199 ] MRCPass - Rheumatology

A 53 year old woman with
rheumatoid arthritis was referred with iron
deficiency anaemia. She had extensive
investigations. Endoscopy showed gastritis
and antral erosions, small bow el biopsy
showing mild villous blunting, and apopotic
bodies, Colonoscopy was normal.

What is the cause of these findings?

1- Methotrexate

2- Azathioprine therapy

3- Crohn's disease

4- NSAID therapy

5- Felty's syndrome

Answer & Comments

Answer: 4- NSAID therapy

The endoscopy findings are suggestive of
NSAID related gastritis, which is the most
likely cause of iron deficiency anaemia.

NSAID related gastritis

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[ Q: 200 ] MRCPass - Rheumatology

A 45 year old woman complains of
12 months of mid and lower back pain
associated with stiffness in her shoulders,
wrists, small joints of the hands, hips knees
and feet. The joint stiffness is more
pronounced in the morning and lasts 2-3
hours and is associated with severe fatigue.

She also experiences occasional pins and
needles affecting all of the right hand and
frequent frontal and temporal headache.

Clinical examination demonstrates no
synovitis but tenderness around the base of
the cervical spine, across the shoulders, over
the costochondral cartilages, greater
trochanter and the knee.

Investigations are as follow s : CRP <5 g/l, ESR
20 mm in the first hour, CK 120 U/l, serum
immunoglobulins and protein electrophoresis
normal.

Whot is the diagnosis?

1- SLE

2- Polymyalgia rheumatica

3- Fibromyalgia

4- Dermatomyositis

5- Polymyositis

Answer & Comments

Answer: 3- Fibromyalgia

1- Staphyloccocus aureus

2- Neisseria gonorrhoeae

3- (3-haemolytic streptococcus

4- Pseudomonas aeruginosa

5- Moraxella catarrhalis

Answer & Comments

Answer: 1- Staphyloccocus aureus

Staph aureus is the commonest organism
(over 50%). Neisseria gonorrhea can occur in
patients with sexually transmitted disease. (3-
haemolytic streptococci can cause impetigo,
sore throat and rheumatic fever. Moraxella is
a gram negative coccus which can cause
pneumonia in COPD patients.

[ Q: 202 ] MRCPass - Rheumatology

A 66 year old lady had a fall and
fractured femur. A DEXA scan shows reduced
bone mineral density consistent with
osteoporosis.

Whot treatment should be given to reduce the
likelihood of future fractures?

1- Alendronate

2- Alendronate and calcium

3- Alendronate, calcium and vitamin D

4- Calcium

5- Vitamin D

The above symptoms are all characteristic for
fibromyalgia. The inflammatory markers and
CK are not raised, making the other diagnoses
unlikely

Answer & Comments

Answer: 3- Alendronate, calcium and vitamin
D

[ Q: 201 ] MRCPass - Rheumatology

A 35 year old man presents with hot
swollen elbow joint. He has a temperature of
37°C and CRP of 350mg/l. A diagnosis of septic
arthritis is suspected.

Which of the following organisms is most
commonly isolated from joints?

Any patient above the age of 65 with
osteoporosis is recommended to be on
bisphosphonates. In addition, this patient has
sustained a fracture, and should also be on
calcium and vitamin D (calcichew D3) as well.

[ Q: 203 ] MRCPass - Rheumatology
A 82 year old woman presents with

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confusion. Of note in her past history was
Raynaud's phenomenon.

Her investigations show :

haemoglobin 9.7 g/dl

white cell count 3.6 x 10 9 /L

platelet count 100 x 10 9 /l_

serum total protein 120 g/l

serum immunoglobulins : IgA 0.75 g/l (0.83),
IgG 16 g/l (6-13), IgM 35 g/l (0.4-2.5)

Which of the following complications is she
likely develop?

1- Urinary tract infection

2- Hyperviscosity syndrome

3- Pathological bone fracture

4- Acute renal failure

5- Erythema nodosum

Answer & Comments

Answer: 2- Hyperviscosity syndrome

The likely diagnosis is Waldenstrom's
Macroglobulinaemia (WM).

Waldenstrom's macroglobulinaemia is a type
of non-Hodgkin's lymphoma. It is a condition
which typically presents in the seventh and
eighth decade of life. It is characterized by the
presence of a high level of a macroglobulin
immunoglobulin M [IgM] and elevated serum
viscosity in the presence of a
lymphoplasmacytic infiltrate in the bone
marrow . The treatment is chemotherapy
(Chlorambucil or Fludarabine).

2- De Quervain's tenosynovitis

3- Osteoarthritis

4- Psoriatic arthritis

5- Rheumatoid arthritis

Answer & Comments

Answer: 3- Osteoarthritis

The tenderness at the carpometacarpal joint is
most likely due to osteoarthritis in a patient of
this age.

^ [ Q: 205 ] MRCPass - Rheumatology

# A 45 year old man presents to the
opthalmologist and was found to have
anterior uveitis. Upon enquiry, he has mouth
ulcers and a rash on his leg.

Whot is the likely diagnosis?

1- AL amyloidosis

2- Familial mediterranean fever

3- Behcet's disease

4- Polymyalgia rheumatica

5- SLE

Answer & Comments

Answer: 3- Behcet's disease

Behget's disease may cause anterior or
posterior uveitis, corneal ulceration,
conjunctivitis, papillitis, SVC and IVC
thrombosis, pulmonary embolism, erythema
nodosum, pustular lesions, acneiform nodules,
pathergy and oral ulceration.

[ Q: 204 ] MRCPass - Rheumatology

A 72 year old woman complained of
pain at the base of her right thumb. There was
tenderness and swelling of the right first
carpo-metacarpal joint. Finkelstein's test is
negative.

What is the most likely diagnosis?

1- Avascular necrosis of the scaphoid

[ Q: 206 ] MRCPass - Rheumatology

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In a patient with SLE, the risk of cardiovosculor
abnormality is increased with presence of
which one of the following?

1- Anticardiolipin antibody

2- Anti- Ro antibody

3- Anti La antibody

4- ANA antibody

5- Anti Jo antibody

Answer & Comments

Answer: 2- Anti- Ro antibody

Anti-Ro is important in pregnancy since it is
associated with babies born with congenital
heart block.

appetite. Investigations show : ESR 95 mm/hr,
normochromic normocytic anaemia and a
positive rheumatoid factor.

The likely diagnosis is:

1- Fibromyalgia

2- Polymyositis

3- Dermatomyositis

4- Polymyalgia Rheumatica

5- Chronic myeloid leukaemia

Answer & Comments

Answer: 4- Polymyalgia Rheumatica

Polymyalgia Rheumatica is associated with
weight loss, anemia & malaise.

[ Q: 207 ] MRCPass - Rheumatology

A 50 year old secretary noticed
tingling and numbness over the palmar
surface of her thumb, index and middle
fingers after several hours at her computer.
Pain in the same areas often occur at night.

What is the diagnosis?

1- Rheumatoid arthritis

2- Gout

3- Dermatomyositis

4- Carpal tunnel syndrome

5- Psoriatic arthritis

Answer & Comments

Answer: 4- Carpal tunnel syndrome

It can also be associated with a false positive
rheumatoid factor, especially in the elderly.

[ Q: 209 ] MRCPass - Rheumatology

A 12 year old boy has fevers. He has
had elbow , shoulder and hip and knee pains
over the last few months. On examination, he
has a temperature of 37.5 C and palpable
hepatosplenomegaly.

Investigations show a CRP of 30 and negative
ANA.

What is the likely diagnosis?

1- Marfan's syndrome

2- Ehler Danlos syndrome

3- Perthe's disease

4- Juvenile chronic arthritis

The diagnosis is carpal tunnel syndrome, and
the symptoms are due to tenosynovitis which
is worsened by repetitive strain imposed by
typing.

5- Osteoarthritis

Answer & Comments

Answer: 4- Juvenile chronic arthritis

[ Q: 208 ] MRCPass - Rheumatology

A 75 year old man complains of pain
and stiffness in both his shoulders. He has lost
1/2 a stone in last 6 weeks due to loss of

Juvenile chronic arthritis (JCA) is a form of
seronegative arthritis in the young (adult form
known as Still's disease) which is rheumatoid
factor and ANA negative. Diagnostic criteria
include high fever, hepatomegaly,

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splenomegaly, lymphadenopathy, serositis
(pleuritis, pericarditis), leucocytosis. Bone
destruction and micrognathia occurs.

[ Q: 210 ] MRCPass - Rheumatology

A 25 year old lady presents to clinic
with a painfully swollen hot right knee. She
gives a 2 week history of migratory
polyarthritis and urethritis. Clinical
examination reveals a pustular skin rash, right
Achilles tendinitis and left plantar fasciitis. She
is HLA-B27 negative.

Whot is the most likely diagnosis?

1- Relapsing polychondritis

2- Reiter's syndrome

3- Gonoccocal arthritis

4- Non specific urethritis

5- Behcet's syndrome

Answer & Comments

Answer: 3- Gonoccocal arthritis

Gonoccocal arthritis classically presents with a
hot joint on a background of a migrating
polyarthropathy. It affects w omen more
frequently than men (4:1) and its highest
incidence is among sexually active adolescent
girls. There is also increased risk during
menstruation and pregnancy.

Tw o forms of arthritis exist -- one with skin
rashes and multiple joint involvement, and a
second, less common, form in which
disseminated gonococcemia leads to infection
of a single joint (monoarticular) and joint fluid
cultures are positive.

[ Q: 211 ] MRCPass - Rheumatology

A 50 year old woman with
longstanding rheumatoid arthritis, and a sicca
syndrome. She presents with increasing
malaise. Investigations showed:

Hb 7.5 g/dl

Neutrophil count 1.2 x 10 9 /L

platelet count 90 x 10 9 /l_

Her ESR was 120 mm/hr and CRP 145 mg/dl

On examination, she was pale and had
palpable splenomegaly of 6 cm edge.

The most likely cause of her haematologic
abnormalities is:

1- Anaemia chronic disease

2- Upper Gl bleed

3- Felty's syndrome

4- Folate deficiency

5- Iron deficiency

Answer & Comments

Answer: 3- Felty's syndrome

Felty's syndrome is the triad of seropositive
arthritis, splenomegaly and neutropenia.

The cause of Felty's syndrome is not known,
but is most commonly associated with
rheumatoid arthritis.

[ Q: 212 ] MRCPass - Rheumatology

32 year old lady upper middle class
white lady who used to be an athlete has been
referred for investigation due to tiredness.
She mentions fatigue which is chronic and
occurs even after minor physical w ork. This
has been going on for 3 years. Investigations
including CK, ESR, EMGs and muscle biopsy
have revealed no obvious medical cause for
this.

Which of the following is the best treatment?

1- Erythropoietin injections

2- Cognitive behavioural therapy

3- Graded exercise programme

4- Codeine

5- Fluoxetine

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Answer & Comments

Answer: 3- Graded exercise programme

Chronic Fatigue syndrome is defined by
symptoms and not signs. The clinical profile of
an individual with CFS is of a high-achieving
student or athlete who usually is female
(80%), white, and middle-class to upper
middle-class. Treatment is largely supportive
and responsive to symptomatology. This
includes physical therapy and modest aerobic
or anaerobic exercise (if possible) to avoid
cardiovascular deconditioning. Sleep may be
addressed with medication; often, melatonin
or night-time amitriptyline is helpful. If
present and severe, pain often is addressed in
a pain clinic.

[ Q: 213 ] MRCPass - Rheumatology

A 45 year old patient presents with
proximal muscle weakness, particularly in the
lower limbs. She has a heliotropic rash around
the eyes and also Gottron's papules.

Which one of the following antibodies is most
strongly associated?

1- La

Gottron's papules

[ Q: 214 ] MRCPass - Rheumatology

A 9-year-old boy is brought to the
paediatrician with complaints of fever for 1
week. He also has cracked lips, which are
painful.

On examination, his eyes are red and he has a
lymph node in the cervical region. Kawasaki
syndrome is suspected.

Which of the following is the best treatment
choice?

1- Intravenous immunoglobulim

2- Hydrocortisone

3- Abxicimab

2- Ro

3- Jo-1

4- Amoxicillin

5- Low molecular weight heparin

4- SCL-70

5- Anti DsDNA

Answer & Comments

Answer: 3- Jo-1

The diagnosis is dermatomyositis. Anti Jo-1
antibody is associated with acute onset
myositis, particularly dermatomyositis. The
limb girdle or proximal muscles are most
severely affected in both polymyositis and
dermatomyositis.

Answer & Comments

Answer: 1- Intravenous immunoglobulim

This is a case of Kawasaki's syndrome, which is
also known as mucocutaneous lymph node
syndrome and occurs mainly in children under
10 years of age. It is a form of vasculitis, which
affects coronary arteries and is associated
with the development of coronary aneurysms.

Aspirin and IV immunoglobulin at high doses is
the treatment of choice. Corticosteroids used
to be contraindicated, but recently trials have
shown that it reduced the risk of heart
damage caused by coronary vessel vasculitis.

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Infliximab is also being used in trials. Warfarin
is used if coronary aneurysms develop as a
complication.

[ Q: 215 ] MRCPass - Rheumatology

A 55 year old woman presents with a
2 month history of pain affecting the cervical
spine and both shoulders, this was preceded
by pain in the lower back and both hips. Early
morning stiffness lasts until lunchtime and she
feels markedly tired and weak. Examination
reveals bilateral knee effusions and a right
carpal tunnel syndrome.

Investigations demonstrate a normochromic
nomocytic anaemia of Hb 9.8 g/dl, ESR 72 mm
in the first hour, CRP 12 g/l, serum
immunoglobulins and protein electrophoresis
show a polyclonal increase in gamma globulins
and elevated alpha 1 and alpha 2 globulins but
no paraprotein band.

What is the most likely diagnosis?

1- Rheumatoid arthritis

2- Paraneoplastic syndrome

3- Mixed connective tissue disease

4- Scleroderma

5- Polymyalgia rheumatica

Answer & Comments

Answer: 5- Polymyalgia rheumatica

Polymyalgia rheumatica (PMR) is a clinical
diagnosis based on pain and stiffness of pelvic
girdle and shoulder. It is more common after
the age of 55.

In contrast to polymyositis there is no
muscular weakness. Early morning stiffness of
the hip and shoulder girdles is common. A
normochromic normocytic anaemia is
associated.

[ Q: 216 ] MRCPass - Rheumatology

A 55 year old man presents with
sudden onset of a right-sided foot drop with
numbness over the dorsum of his right foot.
He has weakness of dorsiflexion and eversion
of his right foot. There is an area of diminished
sensation over the dorsum of the right foot.
He also has a left wrist drop with loss of
sensation over the dorsal aspect of the first
interosseus space. For the last tw o months,
he has lost weight and he had generalized
myalgia.

Investigations reveal:

Hb 11.5 g/dL
WBC 13 x 10 9 /l_

Neutrophils 9.2 x 10 9 /L
Lymphocytes 2.2 x 10 9 /L
ESR 60 mm/lst hour
Urinalysis: Protein ++, Blood ++

The most likely diagnosis is:

1- Tuberculosis

2- Polyarteritis nodosa

3- Sarcoidosis

4- Rheumatoid arthritis

5- Systemic lupus erythematosus

Answer & Comments

Answer: 2- Polyarteritis nodosa

The patient has a systemic illness with
mononeuritis multiplex and renal
involvement. Although all the listed conditions
can cause mononeuritis, PAN is one of the few
connective tissue disorders that usually occur
in middle-aged men unlike RA and SLE, which
are commoner in females.

[ Q: 217 ] MRCPass - Rheumatology

A 60 year old man presents with pain
in his left foot. He mentions that he has had
poor mobility. General examination reveals a

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swollen ankle. Neurological examination
reveals absent ankle jerk and weak foot
flexion/extension on the left. His ESR is 30
mm/hr, CRP is <5mg/l. Joint x ray reveals
subchondral fractures, soft tissue swelling and
a narrowed joint space.

The likely diagnosis is:

1- Charcot's joint

2- Osteoarthritis

3- Gout

4- Juvenile chronic arthritis

5- Previous road traffic accident

Answer & Comments

Answer: 1- Charcot's joint

Charcot joint or neuropathic joint disease can
be caused by diabetic neuropathy, syphillis,
syringomyelia or leprosy. The X ray changes
are reduced joint space with periarticular
destruction, subchondral bodies, loose bodies
and occasionally joint dislocation.

Charcot's joint

[ Q: 218 ] MRCPass - Rheumatology

A 55 year old man presents with
lethargy, polyuria, polydipsia and stiffness of
the hands. He has evidence of an arthopathy
affecting the 2nd & 3rd metacarpophalangeal
joints of both hands. Xray confirms evidence
of degenerative disease at these sites.

Which of the following the likely diagnosis?

1- Behcet's syndrome

2- Haemochromatosis

3- Amyloidosis

4- Reiter's syndrome

5- Osteoarthritis

Answer & Comments

Answer: 2- Haemochromatosis

The characteristic feature of
haemochromatotic arthropathy is
involvement of the second and third
metacarpals. The arthropathy can lead to
extensive joint destruction.

These patients may have episodes of acute,
inflammatory pseudogout from such
deposition.

^ [ Q: 219 ] MRCPass - Rheumatology

* An 22 year old girl presents with a 6
week history of polyarthralgia with early
morning stiffness. Her symptoms responded
well initially to Ibuprofen but she then they
worsen again. She is otherw ise well apart
from a history of acne which well controlled
on Minocycline. Her mother severe
rheumatoid arthritis.

Investigations show : ESR 40 mm/hr, CRP 110
mg/I, rheumatoid factor negative, ANA
strongly positive (1:1600), antidsDNA
antibodies negative.

What is the likely cause of her symptoms?

1- Drug induced lupus

2- Systemic Lupus Erythematosus

3- Psoriatic arthropathy

4- Juvenile chronic arthritis

5- Fibromyalgia

Answer & Comments

Answer: 1- Drug induced lupus

The likely diagnosis is drug induced SLE.
Minocycline is one of the causes well
documented as a cause of drug induced SLE.

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Characteristically, inflammatory markers such
as ESR & CRP are both markedly elevated.
ANA can be strongly positive but AntidsDNA
antibodies are usually negative. Symptoms
usually resolve following withdraw al of the
drug after several months.

[ Q: 220 ] MRCPass - Rheumatology

A 50 year old woman presents to
casualty with a 2 day history of pain and
swelling of the left ankle. She denies any
history of recent trauma. On examination, she
was febrile, temperature 38.3 C. The left ankle
was swollen and very tender with a reduced
range of movement.

Which of the following investigations would be
most helpful?

1- Urate level

2- ESR

3- Rheumatoid factor

4- Aspiration of synovial fluid

5- Knee X ray

Answer & Comments

Answer: 4- Aspiration of synovial fluid

Joint fluid examination is important in
excluding septic arthritis, and can also help to
confim gout or pseudogout.

[ Q: 221 ] MRCPass - Rheumatology

A 35 year old woman with newly
diagnosed rheumatoid arthritis enquires
about risk factors.

Which one of the following is a risk factor for
rheumatoid arthritis?

1- Pneumococcal infection

Answer & Comments

Answer: 2- HLA-DR4

Risk factors for rheumatoid arthritis are :

HLA-DR4

EBV

parvovirus B19 and rubella infections

blood transfusion

smoking (induces RF production)

stress

obesity

Pregnancy and OCP are protective.

[ Q: 222 ] MRCPass - Rheumatology

A 26 year old man presents with a 6
month history of low back pain. The pain
radiates to his buttocks. There is associated
stiffness which is w orse in the morning and
after periods of inactivity.

Which of the following signs is most likely to
be present?

1- Foot drop

2- Positive femoral stretch test

3- Positive Trendelenburg test

4- Sacroiliac joint tenderness

5- Kernig's sign

Answer & Comments

Answer: 4- Sacroiliac joint tenderness

The diagnosis is ankylosing spondylitis as this
is a young patient with lower back pains and
morning stiffness. Sacroilitis is a common
manifestation.

2- HLA-DR4

3- SLE

4- HIV

5- Renal failure

[ Q: 223 ] MRCPass - Rheumatology

A 62 year old man has complains of a
pain in the temples, fevers, sweats and
malaise for 4 weeks. The right side of the face

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was mildly swollen and he experienced visual
loss in the right eye.

On examination, he had prominent and tender
temporal arteries on the right.

Blood tests revealed:

Hb 12.5 g/dl MCV 86 fl

WCC 12 x 10 9 /L platelets 212 x 10 9 /L

ESR of 90 mm/hr

What is the likely diagnosis?

1- Pituitary tumour

2- Grave's disease

3- Paget's disease

4- Cataract

5- Temporal arteritis

Answer & Comments

Answer: 5- Temporal arteritis

The diagnosis is temporal arteritis (giant cell
arteritis).

The complications of Giant Cell Arthritis are
related to arterial inflammation. These
include:

blindness

absent pulses

hypertension

angina

stroke

claudication

Prominent temporal arteries

[ Q: 224 ] MRCPass - Rheumatology

# -

A 60 year old woman presents with a
history of progressive difficulty in climbing
stairs and rising from chairs.

She also complains of difficulty in swallowing.
She complains that her hands discolour and
become cold easily.

On examination she has purple discolouration
of her eyelids and periorbital oedema. There is
weakness of the muscles of her limb girdles.

What is the likely couse of the dysphagia?

1- Oesophageal cancer

2- Dermatomyositis

3- Systemic Lupus Erythematosus

4- Retrosternal goitre

5- Scleroderma

Answer & Comments

Answer: 2- Dermatomyositis

The diagnosis is dermatomyositis. Dysphagia
in dermatomyositis is primarily due to
weakness of the striated musculature of the
posterior pharynx. Dysphagia may also result
from cricopharyngeal obstruction secondary
to inflammation or fibrosis of the
cricopharyngeus muscles.

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[ Q: 225 ] MRCPass - Rheumatology

A 60 year old man is on frusemide
for leg oedema. He presents with a painful
swollen knee. His temperature is 38 °C and he
has a white cell count of 12 x 10 9 /L and CRP of
120mg/l. Uric acid is 0.49 mmol/I (<0.42).

A joint aspirate reveals pus cells and
negatively birefringent crystals with polarized
light. After treatment with NSAIDs for 48
hours he has not improved and the swelling
persists. There are no organisms cultured from
the joint aspirate or blood cultures.

What is the best course of action?

1- Allopurinol

2- MRI to look for osteomyelitis

3- Intravenous flucloxacillin

4- Arthroscopy and washout

5- Further joint aspiration with depomedrone
injection

Answer & Comments

Answer: 5- Further joint aspiration with
depomedrone injection

This is a case of acute gout which has not
settled on medical therapy (NSAIDs or
colchicine). The raised inflammatory markers
can be due to acute gout. Uric acid levels are
not necessarily high in acute gout. A
depomedrone (steroid) injection with further
aspiration of joint fluid is the next step.

[ Q: 226 ] MRCPass - Rheumatology

A 40 year old lady presents with
polyuria and thirst. Her serum calcium of 2.85
mmol/I and a parathyroid hormone of 12 (1-8)
pmol/l. She has normal renal function.

Which test provides the best assessment?

1- CT of her spine

2- Dual energy X-ray absorptiometry

3- Vitamin D levels

4- Isotope bone scan

5- Urine bence jones protein

Answer & Comments

Answer: 2- Dual energy X-ray absorptiometry

This patient is likely to have primary
hyperparathyroidism (secondary to a
parathyroid adenoma). The best assessment is
to determine the severity of loss of bone
density with a DEXA scan in order to consider
parathyroid surgery is necessary.

[ Q: 227 ] MRCPass - Rheumatology

An 45 year old man has had
worsening back pains, shoulder pains and
right hip pain for 8 years. The pain is typically
w orse at the end of day. He also has bony
enlargement of the distal interphalangeal
joints. An X ray of the shoulder reveals the
presence of prominent osteophytes. There is
sclerosis and narrow ing of the joint space at
the hip joints on the pelvic X ray.

What is the likely diagnosis?

1- Osteomyelitis

2- Osteoarthritis

3- Osteomalacia

4- Rheumatoid arthritis

5- Paget's disease

Answer & Comments

Answer: 2- Osteoarthritis

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The clinical history suggests early onset
osteoarthritis (which can be idiopathic or
occur in athletes). The X ray features of
osteophytes, sclerosis and narrow ing of joint
space are suggestive of osteoarthritis.

Osteophyte on a shoulder X ray

[ Q: 228 ] MRCPass - Rheumatology

A 35 year old woman has generalized
joint pains and muscle aches. She also
complains of gritty sensations in the eye in the
mornings. Blood tests show Anti Nuclear
Antibody++, Rheumatoid Factor++.

Whot is the diagnosis?

1- Polylmyositis

2- Reiter's syndrome

3- Primary Sjogren's syndrome

4- Polyarteritis nodosa

5- Rheumatoid arthritis

Answer & Comments

Answer: 3- Primary Sjogren's syndrome

Dry mouth, dry eyes, fatigue, muscle aches
and joint pains are typical of Sjogren's
syndrome. 80% of patients are ANA positive
and 75% are Rheumatoid factor positive. A
useful diagnostic test is the Schirmer's test, w
here a piece of filter paper is placed in the
corner of the eye to measure the degree of w
etting after five minutes.

[ Q: 229 ] MRCPass - Rheumatology

A 60 year old woman presents with a
tw o week history of malaise and lower limb
joint pains. On examination she had a
vasculitic rash over her shins, thighs and
buttocks. Investigations revealed:

Hb 10.2 g/dL

platelets 265 x 10 9 /L

creatinine 380 pmol/L

antinuclear antibodies - Negative

antineutrophil cytoplasmic antibodies
Negative

antiglomerular basement membrane
antibodies - Negative

dipstix urinalysis - blood+++

protein +

What is the likely diagnosis causing renal
impairment?

1- Psoriatic arthritis

2- Henoch Schonlein purpura

3- Polymyositis

4- Membranous nephropathy

5- Myeloma

Answer & Comments

Answer: 2- Henoch Schonlein purpura

The distribution of the rash together with
lower limb joint pains are suggestive of
Henoch Schonlein purpura. This usually occurs
in children aged 2-10 years but can occur in
older age groups. The only w ay of
differentiating this condition from other small
vessel vasculitides is by biopsy. This would
show IgA deposition in vessel w alls on direct
immunofluorescence.

[ Q: 230 ] MRCPass - Rheumatology
A 28 year old woman presents with a

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right knee joint pain and a 4 month history of
weight loss. She thinks she has lost weight
because of diarrhoea, which occurs several
times a day. Examination reveals a swollen,
tender right knee joint with a small effusion.

The likely diagnosis is:

1- Reiter's syndrome

2- Inflammatory bowel disease

3- Behcet's disease

4- Campylobacter infection

5- Rheumatoid arthritis

Answer & Comments

Answer: 2- Inflammatory bowel disease

The description of weight loss, diarrhoea and
a mono/oligoarthropathy suggests a diagnosis
of inflammatory bow el disease. Peripheral
arthritis, peripheral arthralgia without joint
swelling or effusion, degenerative joint
disease or seropositive arthritis can occur in
inflammatory bow el disease. In patients with
peripheral arthralgia and peripheral arthritis,
there is a significantly greater prevalence of
mucocutaneous manifestations of IBD i.e. oral
ulceration, erythema nodosum, pyoderma
gangrenosum, and uveitis.

[ Q: 231 ] MRCPass - Rheumatology

A professional tennis player presents
with shoulder pains especially whilst serving
the ball. He has limited passive and active
shoulder abduction to less than 60°. His
temperature is 36.5°C and he has a normal
white cell count. There is tenderness around
the anterior portion of the shoulder joint.

Which diagnosis is likely?

1- Glenohumeral joint osteoarthritis

2- Bursitis

3- Tennis elbow

4- Supraspinatus tendonitis

5- Septic arthritis

Answer & Comments

Answer: 4- Supraspinatus tendonitis

Pain during abduction with limitation of
movement is suggestive of supraspinatous
tendonitis. Palpation or compression around
the greater tubercle of the humerus is
particularly tender.

[ Q: 232 ] MRCPass - Rheumatology

A 45 year woman has raynauds
phenomenon. She also has difficulty in sw
allow ing and dyspnoea.

Echocardiography shows right heart strain.
Blood tests reveal renal impairment.

Which one of the following antibodies is
specific to this lady’s condition?

1- Anticentromere antibody

2- Topoisomerase I

3- Anti ds DNA antibody

4- Anti SCL 70 antibody

5- Anti mitochondrial antibody

Answer & Comments

Answer: 4- Anti SCL 70 antibody

Anti SCL70 antibody (topoisomerase I) is
typically found in progressive systemic
sclerosis (not the limited cutaneous form,
CREST).

[ Q: 233 ] MRCPass - Rheumatology

A 55 year old man presents with a 6
week history of lethargy and diffuse purpuric
rash. He is noted to have a right foot drop and
a left ulnar nerve palsy. He complains of
arthralgia but has no clinical evidence of
inflammatory joint disease. Echocardiogram is
unremarkable, blood cultures are negative,
ESR 80 mm/hr, ANCA negative, ANA negative,
rheumatoid factor strongly positive, C3 1.1 g/l
(0.75 -1.6), C4 0.03 g/l (0.14 - 0.5).

Dipstick urinalysis shows blood ++.

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What is the likely diagnosis?

1- Takayasu's arteritis

2- ANA negative SLE

3- Culture negative endocarditis

4- Cryoglobulinaemia

5- Rheumatic fever

5- Stimulate parathyroid hormone secretion

Answer & Comments

Answer: 3- Inhibit osteoclasts

Bisphosphonates inhibits osteoclasts and
reduces progression tow ards bone
destruction.

Answer & Comments

Answer: 4- Cryoglobulinaemia

A low C4 together with a strongly positive
rheumatoid factor suggests cryoglobulinaemia
as a cause of mononeuritis multiplex and rash.
Palpable purpura, arthralgia,

hepatosplenomegaly, diffuse proliferative
glomerulonephritis, Raynaud's phenomenon
and thrombosis may occur.

Type I cryoglobulinaemia may be associated
with lymphoproliferative disorders, multiple
myeloma, and monoclonal gammopathy of
uncertain significance, and

macroglobulinaemia. Plasmapheresis may
reduce the levels of cryoglobulin.

[ Q: 235 ] MRCPass - Rheumatology

A 80 year old lady presents with a 5
day history of severe left temporal headache
radiating from her eye to the scalp. She had
also experienced jaw discomfort during
eating.

Which of the following drugs should be given
while awaiting results of diagnostic tests?

1- Carbamazepine

2- Prednisolone

3- Azathioprine

4- Infliximab

5- Intravenous immunoglobulin

Type II cryoglobulinaemia (mixed monoclonal)
is usually composed of a monoclonal
component (usually IgG, IgM or IgA) and a
polyclonal component (mainly IgG). Causes
are connective tissue diseases, Hepatitis B and
C infection, infectious mononucleosis and
lymphoma.

[ Q: 234 ] MRCPass - Rheumatology

A 70 year old woman with a history
of multiple myeloma has a serum calcium of
2.9 mmol/I. He is prescribed pamidronate
infusion over 4 days.

What is its mechanism of action?

1- Promotes calcitonin

2- Increases calcitriol levels

3- Inhibit osteoclasts

4- inhibit osteoblasts

Answer & Comments

Answer: 2- Prednisolone

The history suggests temporal arteritis. In
view of the vision threatening nature of
disease, the patient should be commenced on
steroids. Typically 60mg of prednisolone per
day is recommended.

[ Q: 236 ] MRCPass - Rheumatology

A 30 year old woman has a 3 month
history of arthralgia. There is swelling of the
distal interphalangeal joints of the ring fingers
of the hand. The wrist on the right and ankles
are swollen as well. Onycholysis was noted on
the nails. Her serum inflammatory markers are
raised.

Which of the following is the likely diagnosis?
1- Polymyalgia rheumatica

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2- Rheumatoid arthritis

3- Gout

4- Psoriatic arthropathy

5- SLE

2- CMV infection

3- Tuberculosis

4- Bronchial carcinoma

5- Rheumatoid related pulmonary fibrosis

Answer & Comments

Answer: 4- Psoriatic arthropathy

Answer & Comments

Answer: 3- Tuberculosis

Psoriatic arthritis effects distal interphalangeal
joints tends be asymmetrical.

There are 5 types of psoriatic arthritis.

Asymmetrical oligoarticular arthritis is thought
to be the most common type. Usually, the
digits of the hands and feet are affected first,
with inflammation of the flexor tendon and
synovium occurring simultaneously, leading to
the typical "sausage" appearance (dactylitis).

The other types are symmetrical polyarthritis,
DIP arthropathy, arthritis mutilans and
spondylitis with or without sacroilitis.

Psoriatic arthropathy

[ Q: 237 ] MRCPass - Rheumatology

m A 60 year old lady has severe
rheumatoid arthritis. She is currently on
Methotrexate 20 mg weekly for the past 5
months and also has been receiving regular
infusions of Infliximab. Her joint disease
dramatically improved. She now presents with
fevers, cough and there is evidence a large left
sided pleural effusion on her CXR.

What is the likely diagnosis?

1- Methotrexate pneumonitis

Serious opportunistic infections have been
associated with the anti TNF alpha drug
infliximab, but the frequency of TB exceeds
that associated with other infections.
Infliximab may increase the risk of lymphoma.

[ Q: 238 ] MRCPass - Rheumatology

A 75 year old man presents with an
acute onset of severe pain and swelling of the
left elbow . He mentions that he had a chest
infection 3 weeks ago. On examination, he
had a temperature of 38°C and the left elbow
was erythematous, swollen and tender.

What is the most appropriate investigation?

1- C reactive protein

2- Full blood count

3- Joint aspiration

4- Uric acid level

5- X-ray of the joint

Answer & Comments

Answer: 3- Joint aspiration

This patient is likely to have reactive arthritis.
How ever, gram stain and culture are
necessary to exclude septic arthritis.

[ Q: 239 ] MRCPass - Rheumatology

A 75 year old man has significant
bony pains which have been occuring for 3
years. He presents to the clinic for assessment
and the investigations results were obtained
below:

Corrected calcium 2.4 (2.2 - 2.6)

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ESR 20 mm/lst hr

Alkaline phosphatase 625 iu/L (50 - 100)
gamma GT 42 iu/L (10-50)

Prostate specific antigen 7.4 pg/L (0-6)
What is the most likely diagnosis?

1- Osteoporosis

2- Osteomalacia

2- Morphine

3- Ibuprofen gel

4- Higher dose of codeine

5- Oral hydrocortisone

Answer & Comments

Answer: 3- Ibuprofen gel

3- Metastatic prostatic carcinoma

4- Paget's disease

5- Multiple myeloma

Answer & Comments

Answer: 4- Paget's disease

Paget's disease causes a high alkaline
phosphatase and normal calcium levels.

Paget's Disease represents an imbalance of
bone formation and resorption. It typically
begins with excessive bone resorption
followed by excessive bone formation. The
main disturbance is an exaggeration of
osteoclastic bone resorption.

NSAIDS tend to be better for pain control in
osteoarthritis, but have significant side
effects. Local NSAID application should be
considered as well as intraarticular steroid
injections.

[ Q: 241 ] MRCPass - Rheumatology

A 40 year old lady presents with a
swollen right knee. This was aspirated. Under
the polarised microscope, there were
neutrophils +++ and some blue rhomboidal
crystals under parallel polarised light.

The most likely diagnosis is:

1- Osteoarthritis

2- Rheumatoid arthritis

The most common sites of involvement
include the spine, pelvis, skull, femur and
tibia. Skull involvement may produce
enlargement of the head characterized by
more evident frontal bossing and dilated
superficial cranial muscles.

Conductive and/or sensorineural hearing loss
may result from disease of the temporal bone
or ossicles.

[ Q: 240 ] MRCPass - Rheumatology

A 75 year old patient with
osteoarthritis of the knee has been taking
codeine 30mg qds and also paracetamol
regularly. He continues to have knee pains.

What is the next best treatment?

1- Diclofenac

3- Gout

4- Pseudogout

5- Septic arthritis

Answer & Comments

Answer: 4- Pseudogout

The blue colour and positively birefringent
crystals under polarised light suggest
pseudogout. Neutrophil levels are high in
infection, gout and pseudogout.

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[ Q: 242 ] MRCPass - Rheumatology

A 45 year old man has a renal
transplant. He presents with a hot

swollen ankle on the left and fevers. The
symptoms have been present for 2 days.

What should be done?

1- Check serum uric acid level

Illustration of supraspinatus muscle

2- Inject intra-articular steroids

3- Give colchicine

4- Send joint fluid for microscopy and culture

5- Intravenous cefuroxime

Answer & Comments

Answer: 4- Send joint fluid for microscopy and
culture

The differential diagnosis is gout (common in
renal patients) but the patient will be in
immunosupression and septic arthritis should
be excluded with joint fluid culture.

[ Q: 243 ] MRCPass - Rheumatology

A 40 year old athlete has pain on
abduction of her arm, particularly w hen
resisted.

Which tendon pathology is affected?

1- Biceps tendonitis

2- Supraspinatus tendonitis

3- Teres minor tendonitis

4- Infraspinatus tendinitis

5- Subscapularis tendonitis

Answer & Comments

Answer: 2- Supraspinatus tendonitis

Pain in abduction up to 90 degrees is due to
supraspinatus tendonitis.

[ Q: 244 ] MRCPass - Rheumatology

A 60 year old man has worsening
discomfort in both shoulders. He is
haemodialysis dependent. Past medical
history included bilateral carpal tunnel
decompression. His Investigations reveal:
haemoglobin 9.8 g/dl, ESR 35 mm/lst hr, C
reactive protein 15 mg/L, Urate 0.58.

What is the likely diagnosis?

1- Reiter's syndrome

2- Amyloidosis

3- Polymyalgia rheumatica

4- Gout

5- Osteomalacia

Answer & Comments

Answer: 2- Amyloidosis

b2 microglobulin deposition in joints may lead
to amyloidosis. This can occur 10 years on
from dialysis, and lead to carpal tunnel
syndrome.

^ [ Q: 245 ] MRCPass - Rheumatology

a -

# A 45 year old man presents with a
painful swollen knee. He feels generally
unwell and has fever. He has recently had a
flulike illness, an erythematous rash on the
trunk followed by a self-limiting episode of
diarrhoea. A diagnosis of reactive arthritis is
made by the rheumatologist.

How should the patient be managed?

1- High dose steroids

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2- Broad spectrum iv antibiotics

3- Arthroscopy and washout of the joint

4- If the symptoms becomes chronic,
sulphasalazine may be useful

5- Bone scan to look for a focus of infection

Answer & Comments

Answer: 4- If the symptoms becomes chronic,
sulphasalazine may be useful

The diagnosis is likely to be reactive arthritis
following an infectious illness. Although joint
aspiration may be useful, there is no need for
arthroscopy at present. NSAIDs may be used
for symptoms control now. If the symptoms
persist, sulphasalazine or methotrexate may
be useful.

[ Q: 246 ] MRCPass - Rheumatology

A 16 girl is investigated for swelling
and pain in the right wrist, left knee and right
ankle.

Investigations show a positive ANA 1:160 with
-ve Rheumatoid factor.

What is she at risk of developing?

1- Psoriasis

2- Butterfly facial rash

3- Erosive joint disease

4- Uveitis

juvenile chronic arthritis. Stiffness,
amyloidosis, and osteoporosis also occur.

Uveitis causing red eye (lenticular precipitates

may be seen)

[ Q: 247 ] MRCPass - Rheumatology

A 22 year old man presents with a 4
week history of a painful swollen left knee. He
has a past medical history of a treated sexually
transmitted disease 6 months ago. On
examination there was a large effusion in the
left knee.

Synovial fluid analysis shows a white cell count
of 15 x 10 9 /L but culture was negative.

Which one of the following organisms is the
most likely cause?

1- Gardnerella

2- Chlamydia

3- Treponema pallidum

4- Neisseria gonorrhoea

5- Trichomonas vaginalis

5- Bamboo spine

Answer & Comments

Answer: 4- Uveitis

Juvenile chronic arthritis is a term used to
describe arthritis occurring in someone who is
less than 16 years old that lasts for more than
three months. Large joints tend to be affected.
Rheumatoid factor is often negative, and
there is positive antinuclear antibody -
especially in pauciarticular JCA. Acute anterior
uveitis is most commonly in pauciarticular

Answer & Comments

Answer: 4- Neisseria gonorrhoea

Gonococcal arthritis is caused by an infection
with the gram-negative diplococcus N
gonorrhoeae. Neisseria gonorrhoea occurs in
young adults, often preceded by a migratory
arthritis.

The bacteremic phase is a classic triad of
migratory polyarthritis, tenosynovitis, and
dermatitis. This patient was treated previously
for a sexually acquired infection hence may be
the reason for the culture to be negative.

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The initial treatment of choice for gonococcal
arthritis is a third-generation beta-lactamase-
resistant cephalosporin (eg, ceftriaxone,
ceftizoxime, cefotaxime) or a penicillin, if the
organism is sensitive.

Multiple intracellular gram negative

diplococcic

A 50 year old man presents with chronic
recurrent sinusitis and occasional
haemoptysis. He has middle lobe patchy
shadow ing on his chest X-ray. His creatinine is
145 and urine dipstick shows ++ protein and
blood.

Which test result is most likely?

1- Positive c ANCA

2- Positive ANA

3- Positive Kveim test

4- Positive ASOT

5- Sputum AFB positive

Answer & Comments

Answer: 1- Positive c ANCA

[ Q: 248 ] MRCPass - Rheumatology

A 35 year old lady has positive ANA,
and has a butterfly shaped rash on her face.
Her physician makes a diagnosis of SLE. She
has flare ups of joint swellings and pains
requiring several months treatment with
prednisolone. 1 year later she presents with
hip pain limiting her mobility.

Which one of the following is o likely couse?

1- Rheumatoid arthritis

2- Septic arthritis

3- Juvenile chronic arthritis

4- Avascular necrosis

5- Perthe's disease

Answer & Comments

Answer: 4- Avascular necrosis

Nasal cavity, pulmonary and renal
granulomatous involvement is classical in
Wegener's granulomatosis. 70% of patients
have a positive cANCA. In addition, w hen
ANCA is positive, PR3 (Wegener's) and MPO
(microscopic polyangitis) helps to distinguish
between the two differential diagnoses.

[ Q: 250 ] MRCPass - Rheumatology

A 55 year old female presents
complaining of bone pains and muscular
weakness. Her gait is w addling in nature.

X-ray shows pseudofractures of her pubic
rami.

Investigations show : Serum corrected calcium
2.05 mmol/L, phosphate 0.43 mmol/L, alkaline
phosphatase 230 U/L.

Whot is the diagnosis?

1- Pseudohypoparathyroidism

15% of patients with SLE develop avascular
necrosis of the bone. Nephritis, vasculitis and
long term steroid use predispose to avascular
necrosis.

[ Q: 249 ] MRCPass - Rheumatology

2- Secondary hyperparathyroidism

3- Osteopetrosis

4- Osteomalacia

5- Paget's disease

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Answer & Comments

Answer: 4- Osteomalacia

The clinical radiological and biochemical
features in this patient suggest she has
osteomalacia. Osteomalacia is characterized
by a low serum calcium and phosphate with
elevated serum alkaline phosphatase.

Osteomalacia may be caused by deficiency of
vitamin D or phosphate deficiency.
Malabsorption syndromes, renal failure and
liver disease can result in vitamin D deficiency.

[ Q: 251 ] MRCPass - Rheumatology

A 22 year old Armenian man
presents with pain and swelling of the left
knee. He also gives a history of recurrent
episodes of fever, pleuritic pains in the chest,
and generalised rash. These episodes typically
last for 2-3 days. Examination reveals
splenomegaly, swollen knees and ankles.
Urine dipstick reveals 2+ proteinuria.

What is the likely diagnosis ?

1- Ankylosing spondylitis

2- Reactive arthritis

3- Familial Mediterranean fever

4- Tuberculosis

5- Dermatomyositis

Answer & Comments

Answer: 3- Familial Mediterranean fever

AA amyloidosis commonly involves the
kidneys, spleen and Gl tract. Colchicine given
prophylactically in FMF offers some protection
against the development of amyloidosis in
most patients.

Familial Mediterranean fever primarily affects
populations originating from the
Mediterranean region, particularly people of
Armenian, Arabic, Turkish, and North African
Jew ish ancestry. Mutations in the MEFV gene
cause familial Mediterranean fever.

Rash seen in familial mediterranean fever

[ Q: 252 ] MRCPass - Rheumatology

A 35 year old man presents acutely
with urethritis, conjunctivitis and arthritis. He
has been having joint pains in the wrist and
hips.

On examination, he has a rash on the soles of
his feet and also circinate balanitis.

Rheumatoid factor is negative and he has
raised inflammatory markers.

Familial Mediterranean fever is an inherited
condition characterized by recurrent episodes
of painful inflammation in the abdomen,
chest, or joints. These episodes are often
accompanied by fever and sometimes a rash.
The first episode usually occurs by the age of
20 years, but in some cases, the initial attack
occurs much later in life. Typically, episodes
last 12 to 72 hours and can vary in severity
and in the length of time Between attacks.

Whot is the diagnosis?

1- Behcet's syndrome

2- Rheumatoid arthritis

3- Reiter's syndrome

4- Psoriatic arthropathy

5- Ankylosing spondylitis

Answer & Comments

Answer: 3- Reiter's syndrome

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Reiter's syndrome is urethritis, conjunctivitis,
seronegative arthritis (cannot see, cannot pee,
cannot climb a tree). The typical patient is a
young man with recent urethritis or
dysentery. The seronegative arthritis is usually
a mono or oligoarthritis.

Other features are anterior uveitis,
keratoderma blenorrhagica (brow n abscesses
on palms and soles), mouth ulcers, plantar
fasciitis and archilles tendinitis
(enthesopathy), circinate balanitis (painless
rash) and aortic incompetence. Management
is usually with rest and NSAIDs.

Keratoderma Blenorrhagica in Reiter's

syndrome

[ Q: 253 ] MRCPass - Rheumatology

A 50 year old patient with
rheumatoid arthritis has the following full
blood count results: Haemoglobin 10.5 g/dL,
Platelets 450 x 10 9 /l_, White Cell Count 8.5 x
10 9 /L, MCV 103 fL.

Which drug is the likely cause of this?

1- Infliximab

2- Ciclosporin

3- Leflunomide

4- Prednisolone

5- Methotrexate

Answer & Comments

Answer: 5- Methotrexate

Methotrexate may lead to macrocytosis as a
result of B12 or folate deficiency. It may also
be associated with bone marrow suppression,
causing leucopenia or thombocytopaenia.
Methotrexate may also cause mouth ulcers,
stomatitis, cough and dyspnoea.

^ [ Q: 254 ] MRCPass - Rheumatology

wit

# A 32 year old man has had a year's
history of bilateral hip pains and back pains.
There is not past medical history of trauma to
the back. Non steroidal anti-inflammatory
drugs helped to relieve his symptoms.

What is the likely diagnosis?

1- Gluteus medius tendonitis

2- Osteoarthritis

3- Hip fracture

4- Sacroilitis

5- Osteoarthrosis

Answer & Comments

Answer: 4- Sacroilitis

Pain and stiffness in the lower back or
buttocks, especially in the morning is typical of
sacroilitis. It is typically helped by NSAIDS or
steroids. X rays will help to confirm the
diagnosis. It is associated with various
inflammatory diseases e.g. ankylosing
spondylitis, psoriatic arthritis.

[ Q: 255 ] MRCPass - Rheumatology

A 35 year old lady presents with
stiffness, pain and swelling of her hands and
wrists. On examination she has firm
subcutaneous nodules over her elbow s,
swelling of her wrists, ulnar deviation at the
metacarpophalangeal joints, dinner fork
deformity and swelling of her proximal
interphalangeal joints.

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Investigations reveal a normocytic,
normochromic anaemia, elevated ESR and
CRP.

Which is the most commonly used test which
could determine whether she is sero-positive?

1- IgA antibody

2- IgM antibody

3- IgE antibody

4- IgD antibody

5- IgG antibody

Answer & Comments

Answer: 2- IgM antibody

The patient has features of sero positive
rheumatoid arthritis (presence of rheumatoid
factor). Rheumatoid factor is a circulating
antibody directed against the Fc fragment of
immunoglobulin. The antibody may IgM, IgG,
or IgA. The commonly employed test detects
the IgM rheumatoid factor.

The patient has Sjogren's syndrome. Sjogren
syndrome is a chronic autoimmune disorder
characterized by xerostomia (dry mouth),
xerophthalmia (dry eyes), and lymphocytic
infiltration of the exocrine glands. This triad is
also known as the sicca complex.

The Schirmer test is probably the only test
available in the ED to strongly support or
refute suspicion of Sjogren syndrome. A test
strip of filter paper is placed near the lower
conjunctival sac to measure tear formation. A
positive test occurs when less than 5 mm of
filter paper is wet after 5 minutes.

Rheumatoid factor, ANA, Ro and La antigens
are commonly present.

As a result of the lymphocytic infiltration, 10%
of patients may develop pseudolymphoma, a
lymphoproliferative process. Approximately
10% of these patients can develop non-
Hodgkin lymphoma (1% of all patients with
Sjogren syndrome).

[ Q: 256 ] MRCPass - Rheumatology

A 32 year old man has a 6 month
history of dry eyes and mouth. On
examination, there was evidence of
keratoconjunctivitis, parotid gland
enlargement and a Schirmer's test is positive.

His blood tests reveal a positive ANA, Ro and
La extra nuclear antigens are also positive.

What is the diagnosis?

1- SLE

2- Rheumatoid arthritis

3- Sjogren's syndrome

4- Wegener's granulomatosis

5- Pulmonary eosinophilia

[ Q: 257 ] MRCPass - Rheumatology

A 38 year old lady presents with
myalgia and lethargy. Her blood tests show a
positive ANA with a titre of 1:1024 and
rheumatoid factor is negative.

The CK is raised at 360 U/l. Extranuclear
antigen tests show a negative Ro and negative
La, negative Scl70 and positive ribonuclear
protein antibody at 160 units.

What is the diagnosis?

1- Polymyalgia rheumatica

2- Polymyositis

3- Scleroderma

4- Systemic lupus erythematosus

5- Mixed connective tissue disease

Answer & Comments

Answer: 3- Sjogren's syndrome

Answer & Comments

Answer: 5- Mixed connective tissue disease

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A positive ANA (speckled pattern), raised CK
and positive anti RNP antibody suggests mixed
connective tissue disease.

[ Q: 258 ] MRCPass - Rheumatology

A 50 year old man presents to the
renal team with uraemic symptoms. He also
has markedly reduced range of movement at
the spine with a Schober's test of 10 mm.

His CRP is 102 mg/dl and ESR 98 mm/hr. Urine
dipstick shows proteinuria ++++.

He has had treatment with penicillamine in
the past for arthritis. He takes regular
ibuprofen.

What is the most likely couse of his renal
symptoms?

1- Nephritic syndrome

2- NSAID nephropathy

3- Scleroderma

4- AL amyloid

5- AA amyloid

Answer & Comments

Answer: 5- AA amyloid

Nephrotic range proteinuria and renal failure
in the context of a prolonged untreated
inflammatory response suggests AA amyloid.
Since circulating serum AA is the precursor of
AA amyloid deposits, reduction of the
precursor protein is the most rational
approach at present for the management of
amyloidosis.

Prevention of amyloidosis is preferable to
treatment of the established disease. Thus
aggressive therapy of rheumatic diseases such
as RA and JCA is desirable in this context.

[ Q: 259 ] MRCPass - Rheumatology

A 45 year old woman presents with
confusion. On examination she was pyrexial,

had livedo reticularis had a blood pressure of
190/100 mmHg.

Examination of the abdomen revealed left
flank tenderness.

Investigations revealed:

Hb 13.9 g/dL

white cell count 6.5 x 10 9 /l_

platelet count 110 x 10 9 /L

serum creatinine 95 umol/L

urine dipstick analysis: blood +++, protein +

Which one of the following tests is likely to be
positive?

1- Anti Ro antibody

2- Anti GBM antibody

3- Anti cardiolipin antibody

4- ASOT

5- ANCA

Answer & Comments

Answer: 3- Anti cardiolipin antibody

The diagnosis is SLE and antiphopholipid
syndrome. The presentation would be
consistent with renal vein thrombosis (flank
pain and proteinuria). Antiphospholipid
syndrome (APS) is a disorder characterized by
recurrent venous or arterial thrombosis
and/or fetal losses associated with typical
laboratory abnormalities. These include
persistently elevated levels of antibodies
directed against membrane anionic
phospholipids (ie, anticardiolipin [aCL]
antibody, antiphosphatidylserine).

Vascular thrombosis - DVT, Ml, CVA or
miscarriages may occur. Other features are
nonthrombotic neurologic symptoms, such as
migraine headaches, chorea, seizures,
transverse myelitis, Guillain-Barre syndrome,
thrombocytopenia or hemolytic anemia,
Livedo reticularis, Avascular necrosis of bone
and Pulmonary hypertension.

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Aspirin or warfarin is recommended for
patients with thrombotic syndromes.

[ Q: 260 ] MRCPass - Rheumatology

A 60 year old lady has
polyarthropathy due to Rheumatoid Arthtitis.

Which one of the following molecules ploys o
central role in its pathogenesis?

1- IFN gamma

2- Interleukin 8

The diagnosis is CREST syndrome. Renal
hypertensive crisis is more common in diffuse
systemic sclerosis and pulmonary
hypertension is more common in limited
cutaneous scleroderma.

[ Q: 262 ] MRCPass - Rheumatology

An 18 year old girl developed
pulmonary haemorrhage and subsequent
acute renal failure requiring dialysis. A renal
biopsy shows crescentic glomerulonephritis.

3- TNF alpha

4- Endotoxin

5- Nitric oxide

Answer & Comments

Answer: 3- TNF alpha

In the context of rheumatoid arthritis, TNF a
has involvement in cytokine regulation, cell
recruitment, angiogenesis, and tissue
destruction. Hence anti TNF alpha antibodies
such as infliximab are used in therapy.

^ [ Q: 261 ] MRCPass - Rheumatology

fi -

# A 50 year old woman presents with
breathlessness. She has a 2 year history of
Raynaud's. On examination, she had
telangiectasia and tight skin around the
mouth. Her investigations show an ESR of 70
mm/hr and positive anti-centromere
antibodies.

Which one of the following antibodies is likely
to be present?

1- Anti mitochondrial

2- Anti centromere

3- Anti nuclear

4- Anti phospholipid

5- Anti myeloperoxidase

Answer & Comments

Answer: 5- Anti myeloperoxidase

This patient manifests a pulmonary renal
syndrome which is commonly due to an ANCA
positive vasculitis. P ANCA which correlates
with antimyeloperoxidase (MPO) antibodies,
is highly sensitive and specific tow ards rapidly
progressive glomerulonephritis and

haemorrhagic alveolar capillaritis. Less
commonly this could be due to Goodpasture's
syndrome (anti GBM antibodies).

Which of the following is a typical late
complication of this disorder?

1- Renal hypertensive crisis

2- Lung malignancy

3- Pulmonary hypertension

4- Myositis

5- Mitral regurgitation

Answer & Comments

Answer: 3- Pulmonary hypertension

[ Q: 263 ] MRCPass - Rheumatology

A 65 year old man with chronic
leukaemia presents with symptoms of gout.
He was given Allopurinol.

How does Allopurinol prevent accumulation of
uric acid?

1- By increasing uric acid metabolism

2- By enhancing its solubility

3- By inhibiting purine synthesis

4- By inhibiting pyrimidine synthesis

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5- By inhibiting xanthine oxidase

Answer & Comments

Answer: 5- By inhibiting xanthine oxidase

Transient osteoporosis of the hip is also a
recognised cause of hip pain in pregnancy, but
plain radiographs would usually show marked
unilateral osteopenia of the femoral head and
acetabulum.

Allopurinol inhibits xanthine oxidase, the
enzyme that catalyzes the conversion of
hypoxanthine to xanthine and of xanthine to
uric acid. Hypoxanthine and xanthine are
breakdown products of purine.

I II >-H

Hypoxanthine

Xanthine

oxidase

j j >- h

I >

H H

Xanthine

OH H

' l

■ I II >

Allopurinol

1 11 ;

C-H

Xanthine

oxidase

Hv n^ C ^c^ n \

II c-o

l H H

Uric acid

[ Q: 264 ] MRCPass - Rheumatology

A 32 year old woman in the third
trimester of her second pregnancy develops
acute onset right groin pain.

On examination, all right hip movements are
painful and she is tender in the right groin and
over the greater trochanter. Lumbar spine
examination shows an exaggerated lordosis
only and there are no neurological lower limb
deficits. Initial plain films of the hip are
normal.

The most likely diagnosis is :

1- Septic arthritis

2- Hip dislocation

3- Avascular necrosis of the hip

4- Pregnancy exacerbating osteoarthritis

5- Pseudogout

Answer & Comments

Answer: 3- Avascular necrosis of the hip

This is a classical presentation of avascular
necrosis of the femoral head in pregnancy.

The arterial supply to the femoral head is
easily damaged with any femoral neck
fracture displacement.

Atraumatic causes of this are : Alcohol abuse,
Chemotherapy, Chronic liver disease,
Corticosteroids, Gaucher disease, Gout,
Hemoglobinopathy (eg, sickle cell disease),
Metabolic bone disease, Pregnancy, Radiation,
Systemic lupus erythematosus, Vasculitis.

[ Q: 265 ] MRCPass - Rheumatology

A 55 year old woman with psoriasis
has significant joint pains.

Which one of the following is effective in the
treatment of psoriatic arthropathy?

1- Codeine phosphate

2- Methotrexate

3- Beta interferon

4- Capacitabine

5- Buprenorphine

Answer & Comments

Answer: 2- Methotrexate

NSAIDs, sulphasalazine, methotrexate and TNF
alpha antagonists are useful in psoriatic
arthropathy.

[ Q: 266 ] MRCPass - Rheumatology

A 65 year old woman attends has a
12 week history of lethargy, neck pains and
weakness in the lower limbs.

She has a long history of lower back pains and
generalised osteoarthritis. She takes
diclofenac regularly.

On examination there is wasting of her upper
limbs. Tone mildly increased in the lower

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limbs. There is inversion of right supinator
reflex, triceps, knee and ankle jerks are brisk
bilaterally. Right plantar is extensor and the
left is flexor.

Investigations show:

Hb 11.6 g/l

WCC 8 x 10 9 /L

Plat 160 x 10 9 /L

ESR 73 mm

CRP 12 mg/I

Na 138 mmol/I

K 4.4 mmol/l

Urea 5.8 mmol/l

Creatinine 95 umol/l

Protein 83 g/l

Albumin 32 g/l

Ca 2.33 mmol/l

X ray cervical spine shows extensive
osteophytes

What is the likely diagnosis?

1- Ankylosing spondylitis

2- Polymyalgia rheumatica

3- Cervical spondyloarthropathy

4- Multiple sclerosis

5- Syringomyelia

Answer & Comments

Answer: 3- Cervical spondyloarthropathy

On examination, he appears unwell and has a
temperature of 38°C.

Investigations reveal:

Hb 8.5 g/dL

erythrocyte sedimentation rate 95 mm/hr

serum creatinine 220 pmol/L

urine analysis: blood ++

urine microscopy: white cells & red cell casts
seen

Which one of the following is the likely
diagnosis?

1- Multiple myeloma

2- Antiphospholipid syndrome

3- Takayasu's arteritis

4- Polyarteritis nodosa

5- Goodpasture's syndrome

Answer & Comments

Answer: 4- Polyarteritis nodosa

This patient has a mononeuritis multiplex,
fever and nephritic renal involvement
suggesting a diagnosis of polyarteritis nodosa.
PAN causes transmural necrotizing
inflammation of small-sized or medium-sized
muscular arteries. PAN is a rare condition.

Although the causes are unknown in most
cases, there is an association with: Hep B
virus, Hep C virus, HIV, Cytomegalovirus,
Parvovirus B19 and Human T-lymphotrophic
virus.

Cervical spondylosis may present with
associated pains in the neck radiating down
the arms and back. There may be upper motor
neuron signs in the upper and lower limbs.

[ Q: 267 ] MRCPass - Rheumatology

A 70 year man presents with right
foot drop, hand numbness, fevers, malaise,
weight loss, polymyalgia and diffuse joint
pains for 2 months.

Approximately 20% of patients with classic
PAN are positive for P-ANCA. Steroids
(prednisolone) and immunosuppressive
(cyclophosphamide) medications form the
backbone of therapy. Plasma exchange is
useful as a second-line treatment in PAN
refractory to conventional therapy.

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[ Q: 268 ] MRCPass - Respiratory

A man presents with symptoms
suggestive of a pneumonia. The CXR confirms
this.

Which of the following features suggests poor
prognosis?

1- Respiratory rate of 20

2- Temperature 38°C

3- Age 60

4- Urea of 10

5- MTS score of 9 out of 10

Answer & Comments

Answer: 4- Urea of 10

Answer & Comments

Answer: 4- PH <7.2

Although a high protein also points tow ards
an exudates, a low pH is the best marker of
infection in an effusion requiring chest drain
insertion.

[ Q: 270 ] MRCPass - Respiratory

A 75 year old heavy smoker presents
to the hospital with breathlessness, wheezing
and a cough with yellow sputum.

He has the following investigations: Hb 18
g/dl, WCC 12 x 10 9 /L, ABGs show a pH of 7.38,
p0 2 of 8.5 kPa, pC0 2 of 7 kPa.

What is the diagnosis?

The CURB-65 score for poor prognosis in
pneumonia are :

confusion (defined as an AMT of 8 or
less)

urea greater than 7 mmol/I
respiratory rate of 30 breaths per
minute or greater

blood pressure less than 90 systolic or
diastolic blood pressure 60 or less
age 65 or older

1- Bronchiectasis

2- Chronic obstructive pulmonary disease

3- Mesothelioma

4- Tuberculosis

5- Cryptogenic fibrosing alveolitis

Answer & Comments

Answer: 2- Chronic obstructive pulmonary
disease

[ Q: 269 ] MRCPass - Respiratory

A 60 year old lady presents with
shortness of breath. A chest X ray confirms
that she has a right sided pleural effusion. An
Aspirate was taken and the sample was sent
for several tests.

Which one of the following is an indication for
a chest drain?

1- High protein

2- Low glucose

3- Low LDH

4- PH <7.2

5- Blood stains

This patient has type II respiratory failure,
without an acidosis, suggesting chronic C02
retention. He also is a heavy smoker and has
polycythaemia, making COPD most likely.

[ Q: 271 ] MRCPass - Respiratory

A 45 year old man presents with a
chronic cough productive of copious amounts
of thick yellow sputum and occasional
haemoptysis. He also has had multiple
episodes of chest infection. On examination
he has clubbing and on auscultation over the
lung bases, coarse crepitations are heard.

Which investigation will reveal the diagnosis?

1- Chromosome testing

2- Bronchoscopy

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3- Sweat test

4- Maxillary sinus x rays

5- High resolution CT

Answer & Comments

Answer: 5- High resolution CT

The diagnosis is bronchiectasis. HRCT is likely
to show bronchial dilatation and wall
thickening.

HRCT showing bronchiectasis

[ Q: 272 ] MRCPass - Respiratory

A 40 year old man has emphysema.
He is found to have the SS phenotype.

What is his alpha 1 antitrypsin level likely to
be?

1 - 10 %

2- 15%

3- 25%

4- 50%

5- 75%

Genotype

Prevalence

Reduction AAT
level (%)

0.1

0.03

[ Q: 273 ] MRCPass - Respiratory

A 70 year old man with known
chronic obstructive pulmonary disease (COPD)
is admitted with symptoms of worsening
breathlessness and confusion. Following a
dose of 200mg iv hydrocortisone and two
doses of salbutamol and atrovent nebulisers,
arterial blood gases were taken.

His arterial blood gases are as follows: pH
7.18, p0 2 6.6 kPa , pC0 2 12.0 kPa.

What should be done next?

1- Repeat dose of corticosteroids

2- Mechanical ventilation

3- 2 litres oxygen

4- Monteleukast

5- Magnesium infusion 2g

Answer & Comments

Answer: 2- Mechanical ventilation

This patient has type II respiratory failure with
acidosis, and hence should be considered for
ventilation, either straight away or with a trial
of NIPPV beforehand.

Answer & Comments

Answer: 4- 50%

The normal genotype is MM and levels of
enzyme is (100%). The relevant enzyme levels
are MS (75%), MZ (55%), SS (50%) ZZ (15%.)

[ Q: 274 ] MRCPass - Respiratory

A 40 year old woman has been
breathless and is undergoing investigations for
the cause. She has a previous history of being
a smoker and has a dry cough as well. Her
ABGs show a p0 2 of 9 kPa and pC0 2 of 5 kPa.
Lung function tests show reduced vital
capacity, reduced TLCO but increased KCO.

What is the likely diagnosis?

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1- COPD

2- Bronchial obstruction from a tumour

3- Kyphoscoliosis

4- Obstructive sleep apnoea

5- Fibrosing alveolitis

Answer & Comments

Answer: 3- Kyphoscoliosis

In this scenario, the lung function indicates
that the surface area for exchange are
inadequate (low TLCO) hence suggesting that
lung expansion is reduced. How ever, cardiac
output is increased to compensate, and
henced KCO is increased. Kyphoscoliosis
would restrict lung expansion, or a
neuromuscular disorder (eg spina bifida) could
cause this.

[ Q: 275 ] MRCPass - Respiratory

A 50 year old woman is admitted
with infective exacerbation of asthma. She
responds to medical treatment but Aspergillus
fumigatus is eventually cultured from her
sputum.

Further investigations show serum total IgE
level was elevated at 350 ng/ml (normal 40-
180 ng/ml), RAST to Aspergillus fumigatus was
class III, Aspergillus fumigatus precipitins are
negative.

What is the most appropriate management?

1- No change in medication

2- High dose oral corticosteroids

3- CT scan of the chest

4- Chest X ray

5- Itraconazole

Answer & Comments

Answer: 1- No change in medication

With negative Aspergillus fumigatus
precipitins and serum total IgE less than 1000

ng/ml, this patient is unlikely to have Allergic
Bronchopulmonary Aspergillosis (ABPA).

Features which are found commonly in
asthmatics without ABPA include:

Positive immediate skin reactivity to
Aspergillus fumigatus, which is present in 20-
30% of asthmatics Positive serum precipitins
to Aspergillus, which occur in 10% of
asthmatics without ABPA Recurrent mucoid
impaction and atelectasis Peripheral blood
eosinophilia and elevation of serum total IgE.

[ Q: 276 ] MRCPass - Respiratory

A 60 year old man presents with
small amounts of haemoptysis and
breathlessness. He does not have pleuritic
chest pains and has normal oxygen
saturations.

In considering the potential diagnosis,
haemoptysis can occur with which of the
following diagnosis?

1- Pulmonary fibrosis

2- Melanoma

3- Goitre

4- Thymoma

5- Aspergilloma

Answer & Comments

Answer: 5- Aspergilloma

Haemoptysis can be caused by pulmonary
embolus, tuberculous infection, aspergilloma,
bronchial carcinoma, Goodpasture's syndrome
and Wegener's granulomatosis.

[ Q: 277 ] MRCPass - Respiratory

A 30 year old man gives a six-month
history of worsening breathlessness and
coughs up half a cupful of sputum daily. He
was occasionally wheezy with viral illnesses as
a young child, works in a factory and has

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smoked 25 cigarettes per day for the last four
years.

The most likely diagnosis is:

1- Lung carcinoma

2- Bronchiectasis

3- Asthma Asbestosis

4- Chronic obstructive pulmonary disease

5- Rheumatoid lung

Answer & Comments

Answer: 2- Bronchiectasis

Bronchiectasis is most likely due to the
extensive amounts of sputum production. In a
young person, cystic fibrosis and
hypogammaglobulinaemia should be
considered.

[ Q: 278 ] MRCPass - Respiratory

A 60 year old man has smoked for 10
years. He has a longstanding dry cough and
expiratory wheeze.

Examination reveals scattered rhonchi and
reduced lung expansion.

The most likely diagnosis is:

1- Asthma

2- Lung carcinoma

3- Chronic bronchitis

4- Bronchiectasis

5- Extrinsic allergic alveolitis

Answer & Comments

Answer: 3- Chronic bronchitis

The heavy smoking history and wheeze
suggests chronic bronchitis.

[ Q: 279 ] MRCPass - Respiratory

A 14 year old boy develops red eye
and rhinitis frequently during the start of the
summer.

What is the likely triggering agent?

1- House dust mite

2- Grass pollen

3- Willow pollen

4- Isocyanates

5- Coal dust

Answer & Comments

Answer: 2- Grass pollen

Grass pollen is released late May till August,
and willow pollen is released from March till
June. As the allergic rhinitis is triggered during
the start of summer, this is most likely to be
due to grass pollen.

[ Q: 280 ] MRCPass - Respiratory

A 65 year old man presents with
breathlessness that has got gradually worse
over three months. He has long-standing atrial
fibrillation, for which he takes warfarin and
amiodarone.

On examination his pulse is 100/min in AF,
oxygen saturation was 90% on air. His JVP was
not raised and he has fine bibasal crackles.
Arterial blood gas saturation showed mild
hypoxia and a pulmonary function test
revealed a moderate restrictive picture.

The most likely diagnosis is:

1- Bronchiectasis

2- Pulmonary embolism

3- Pulmonary haemorrhage

4- Amiodarone induced interstitial lung
disease

5- Congestive cardiac failure

Answer & Comments

Answer: 4- Amiodarone induced interstitial
lung disease

The case scenario would fit amiodarone
induced interstitial lung disease or pulmonary

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fibrosis. This may take several months or years
to develop. Lung function tests may show a
restrictive picture with reduced transfer
factor. A high resolution CT in this case is likely
to show diffuse "ground glass" opacities or
interlobular septal thickening.

[ Q: 281 ] MRCPass - Respiratory

A 65 year old man has been
confirmed to have lung cancer.

Which form of cancer has the worst
prognosis?

1- Small cell

2- Squamous cell

3- Adenocarcinoma

4- Large cell

5- Prostate metastasis

Answer & Comments

Answer: 1- Small cell

Small cell lung cancer has the worst prognosis
out of all lung cancers and is rarely suitable for
surgical resection. Even when diagnosed early
the 2-year survival is in the order of 20-25%.
The main form of therapy is chemotherapy.

Small cell cancer is associated with syndrome
of inappropriate antidiuretic hormone (ADH)
and squamous cell cancer is associated with
paraneoplastic hypercalcaemia through
increased parathyroid-related hormone. 75%
of small cell cancers arise in the proximal
airways.

[ Q: 282 ] MRCPass - Respiratory

A 22 year old female presents with a
chest infection. She is unable to complete a
sentence and her peak flow rate was 40% of
her normal level. She is treated with high flow
oxygen, nebulised bronchodilators and oral
steroids but this is associated with little
change in her condition.

Which of the following treatments, given
intravenously , would be the most appropriate
for this patient?

1- Aminophylline

2- Augmentin

3- Hydrocortisone

4- Magnesium

5- Salbutamol

Answer & Comments

Answer: 4- Magnesium

IV magnesium is recommended by the British
Thoracic Society in severe exacerbation of
asthma. A dose of 2g (8 mmol) is given as a
bolus iv dose in the acute presentation period.

[ Q: 283 ] MRCPass - Respiratory

A 60 year man has been a smoker of
20 a day for 30 years. He has a cough and
difficulty in breathing for 3 days which has
worsened and he presents to hospital. He has
home nebulisers but not home oxygen.

On examination, his oxygen saturations are
95%, blood pressure 110 / 60 mmHg and
respiratory rate 32. He has diffuse wheezes
and is using his respiratory muscles. Arterial
blood gases done on 6 litres of oxygen show :

pH 7.25

p0 2 16 kPa

pC0 2 8.2 kPa

What should be the next management step?

1- Non invasive ventilation

2- Intravenous antibiotics

3- Intubation and ventilation

4- Reduce inspired oxygen concentration

5- Increase oxygen concentration

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Answer & Comments

Answer: 4- Reduce inspired oxygen

concentration

This man with Chronic Obstructive Pulmonary
Disease (COPD) has blood gases showing type
II respiratory failure with acidosis. He has been
placed on 6 litres of oxygen, which is too much
for a patient with severe COPD as the history
of home nebuliser use suggests.

His respiratory drive is suppressed by too
much oxygen inspired, and hence reduction to
a lower concentration (e.g. 1 - 2 litres) to
maintain a p02 above 8.5 kPa is
recommended.

reveals a left-sided pneumothorax with a lung
edge measured 5 cm away from the chest
wall.

The most appropriate management of his
condition is:

1- Review with daily chest radiographs

2- Intercostal tube drainage

3- Refer to a respiratory outpatient clinic

4- CT chest

5- Simple aspiration

Answer & Comments

Answer: 2- Intercostal tube drainage

[ Q: 284 ] MRCPass - Respiratory

A 70 year woman has a history of dry
cough for 2 months. She has lost 5 kg of
weight over the 2 months. Her chest X ray
shows a left apical shadowing. Blood tests
reveal a raised white cell count of 16. She has
not managed to cough up any sputum.

Which test should be performed?

1- CT scan of the chest

2- Serum ANCA

3- Ultrasound of the chest

4- Kveim test

5- Bronchoscopy

Answer & Comments

Answer: 5- Bronchoscopy

This patient is likely to have TB due to the
apical shadowing. In a patient who is unable
to expectorate sputum, bronchoscopy with
lavage (send for AFB) should be performed to
confirm the diagnosis.

[ Q: 285 ] MRCPass - Respiratory

A 65 year old man with emphysema
presented with increasing dyspnoea and left¬
sided pleuritic chest pain. A chest radiograph

The lung edge measurement suggests a
greater than 50% pneumothorax. A smaller
pneumothorax may be amenable to
aspiration. In the context of chronic
underlying respiratory disease such as chronic
obstructive pulmonary disorder and a large
pneumothorax, patients are best managed by
pleural drainage.

[ Q: 286 ] MRCPass - Respiratory

A 70 year old man attends the
hospital with a history of proximal muscle
weakness. He also gives a history of cough of
12 weeks duration and complains of pain of
the small joints of the hands. He has small
haemorrhages in the nail folds, but is not
clubbed. On examination of the chest he has
bibasal crackles, and a chest radiograph
reveals diffuse reticular infiltrates. Lung
function tests confirm a restrictive pattern.

What is the likely cause of his interstitial lung
disease?

1- SLE

2- Dermatomyositis

3- Ankylosing spondylitis

4- Cryptogenic fibrosing alveolitis

5- Amiodarone induced fibrosis

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Answer & Comments

Answer: 2- Dermatomyositis

In polymyositis and dermatomyositis patients
often develop proximal muscle weakness and
of pain in the small joints of the fingers. They
may have ragged cuticles and haemorrhages
at the finger nail folds. Interstitial lung disease
can occur. Underlying malignancy (lungs,
ovaries, breasts and stomach) is present in 5%
of cases.

Bronchiectasis- Airway dilatation on the HRCT

[ Q: 287 ] MRCPass - Respiratory

A 40 year old man is referred for
investigation of the cause of chronic cough. He
describes long standing sputum production
which is streaked with blood. There is no fever
or night sweats, and he does not smoke. How
ever there is a family history of such
symptoms. Chest X ray shows mild bilateral
lower zone shadowing.

[ Q: 288 ] MRCPass - Respiratory

A 40 year old man has a 3 month
history of cough and dyspnoea. He smokes 20
a day. There is no history of asbestos
exposure.

His WBC count is 24 x 10 9 /l_ with 70%
neutrophils and 3.0 x 10 9 /L (5%) eosinophils.
IgE level is elevated.

Which is the most appropriate investigation?

1- High resolution CT

2- Exercise tolerance test

3- Echocardiography

4- Bronchoscopy and biopsy

5- Serum precipitins

He has decreased breath sounds
corresponding to parenchymal infiltrates on
the CXR.

Which is the best test to confirm the
diagnosis?

1- Sputum for Acid Fast Bacilli

2- HIV test

Answer & Comments

Answer: 1- High resolution CT

The likely diagnosis is bronchiectasis, and a
family history is suggestive of cystic fibrosis or
Kartagener's syndrome. HRCT will help to
confirm the diagnosis, if changes such as
dilated central tubular bronchi and mosaic
oligaemia were seen.

3- Autoimmune screen

4- Aspergillus RAST

5- Stool for ova, cysts, parasites

Answer & Comments

Answer: 4- Aspergillus RAST

The condition described is Allergic Broncho
Pulmonary Aspergillosis, which is commoner
among asthmatics and cystic fibrosis patients.
Eosinophilia and high IgE levels are suggestive
of this condition. RAST test for antibodies tow
ards Aspergillus confirms the diagnosis.

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^ [ Q: 289 ] MRCPass - Respiratory

zi -

# A 45 yearold woman is admitted
with a 2-day history of fever, rigors and
breathlessness. She looks extremely unwell
and is confused, cyanosed, has a respiratory
rate of 24/min and a systolic blood pressure of
85 mmHg.

There is bronchial breathing at her right base,
where a chest radiograph reveals
consolidation.

Which would be the most appropriate
antibiotic regimen?

1- Intravenous ceftazidime and intravenous
gentamicin

2- Oral erythromycin

Intravenous cefotaxime

and

oral

erythromycin

Intravenous amoxicillin

and

oral

clarithromycin

5- Oral amoxicillin and oral clarithromycin

Answer & Comments

Answer: 3- Intravenous cefotaxime and oral
erythromycin

Severe pneumonia as defined by the British
Thoracic Society guidelines, is diagnosed when
there are two of the following features:
confusion, urea >7mmol/l, respiratory rate
>30/min, and hypotension (SBP <90mmHg,
DBP <60mmHg).

Appropriate treatment is with intravenous
antimicrobials: cefuroxime 1.5g three times
daily or cefotaxime lg three times daily daily
PLUS erythromycin 500 mg four times daily or
clarithromycin 500mg twice daily.

^ [ Q: 290 ] MRCPass - Respiratory

# A 72 year old man presents with a
history of worsening breathlessness and
cough. His arterial blood gases show the
following recordings when taken at room air:

pH 7.25

p0 2 6.4kPa

pC0 2 8.9 kPa

Bicarbonate 31mmol/L

What is the most likely diagnosis?

1- Acute exacerbation of chronic obstructive
pulmonary disease

2- Obstructive sleep apnoea

3- Pulmonary oedema

4- Pulmonary embolus

5- Pulmonary fibrosis

Answer & Comments

Answer: 1- Acute exacerbation of chronic
obstructive pulmonary disease

The blood gas result would be most
compatible with a patient with severe COPD
and chronic type 2 respiratory failure with an
acute exacerbation (Hypoxia, respiratory
acidodis with raised C02 and metabolic
compensation).

[ Q: 291 ] MRCPass - Respiratory

A 70 year old man presents with a
chronic cough. He is a heavy smoker of over
40 cigarettes a day. CXR shows a peripheral
right-sided lesion. A biopsy which was taken
shows squamous cell carcinoma. No regional
lymph nodes are involved. Lung function tests
show a FEVi of less than 1.5 litres.

The recommended treatment is:

1- Chemotherapy

2- Radiotherapy

3- Lobectomy

4- Pneumectomy

5- Lung transplant

Answer & Comments

Answer: 2- Radiotherapy

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Although surgical treatment is possible in non
small cell lung carcinoma, a FEVi of less than
1.5 litres contraindicates surgery. Hence,
radiotherapy is recommended.

[ Q: 292 ] MRCPass - Respiratory

A 55 year old gentleman has pickw
ickian syndrome. He has poor exercise
tolerance of 50 yards and often feels lethargic
at work.

Which of the following is the best
investigation?

1- Echocardiography to assess cor pulmonale

1- Normal

2- Mixed defect

3- Obstructive defect

4- Restrictive defect

5- Suggestive of haemorrhage

Answer & Comments

Answer: 4- Restrictive defect

Reduced FEVi and FVC with normal FEVi ratio
is compatible with restrictive defect.

Causes of restrictive lung defect are :

2- CT scan of the chest

3- Blood gas

4- Sleep study

5- Exercise tolerance test

Answer & Comments

Answer: 4- Sleep study

neurogenic or psychogenic causes
abnormalities of the thoracic wall
stiff parenchyma (pulmonary fibrosis)
loss of lung tissue, e.g.
pneumonectomy
displacement

The diagnosis of obstructive sleep apnoea can
be made with a sleep study
(polysomnography). In sleep apnoea, there is
gross obesity and airways obstruction,
occasionally leading to type II respiratory
failure. During the sleep study, > 10 episodes
of apneic episodes (pauses in breathing)
satisfies the criteria for obstructive sleep
apnoea.

[ Q: 293 ] MRCPass - Respiratory

A 60 year old man smoker of 35 pack
years presents with a 6 month history of
shortness of breath. His past medical history
includes diabetes and cervical spondylosis.

Spirometry shows FEVi of 1 litre - 65%
predicted

FVC 1.03 litres - 57% predicted
FEVi/FVC ratio of 95.

How would you interpret the spirometry
results?

[ Q: 294 ] MRCPass - Respiratory

A 65 year old man has worsening
breathlessness. He has a past medical history
of arthritis and palpitations.

On admission his oxygen saturations were
90% on air.

ABGs show p02 9 kPa. pC02 3.5 kPa, pH 7.36.

His chest X ray shows patchy shadowing in
both lung peripheries.

Which one of the following drugs is likely to be
responsible?

1- Codeine

2- Tramadol

3- Simvastatin

4- Amiodarone

5- Prednisolone

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Answer & Comments

Answer: 4- Amiodarone

The hypoxia and X ray changes suggest
pulmonary fibrosis. Out of the list of
medications, amiodarone is the most likely
candidate. A lung function test with transfer
factor and also high resolution CT will help to
confirm the diagnosis of amiodarone related
pulmonary fibrosis.

1- Trial of inhaled corticosteroids

2- Trial of anticholinergics

3- Serial peak flow measurements

4- Lung function tests

5- Chest X ray

Answer & Comments

Answer: 3- Serial peak flow measurements

[ Q: 295 ] MRCPass - Respiratory

A 65 year old man has been
diagnosed with chronic obstructive pulmonary
disease (COPD). Spirometry confirms severe
COPD with a FEVi of less than 25% predicted.
In the last year he has been admitted to
hospital on 6 occasions with COPD
exacerbation.

Which one of the following con help to reduce
hospital admissions?

1- Tiotropium

2- Monteleukast

3- Oral theophyllines

4- Salmeterol

5- Hydrocortisone

Answer & Comments

Answer: 1- Tiotropium

The history of wheezing during pollen
exposure suggests asthma. The best
diagnostic test for asthma would be
demonstration of variable airways obstruction
with serial peak flow measurements.
Asthmatic patients with exacerbation will
demonstrate peak flows lower than their
predicted peak flow, and also a morning dip.
There is also reversibility if a bronchodilator
(e.g. salbutamol) is administered.

[ Q: 297 ] MRCPass - Respiratory

A 27 year old man presents with
sudden onset left sided pleuritic chest pain
and breathlessness.

On examination he is distressed, tachypnoeic
and has tracheal displacement to the right
together with a hyper-resonant percussion
note on the left side. There were no breath
sounds on the left. Chest x ray shows a < 2 cm
left sided pneumothorax.

Severe COPD is diagnosed if the FEVi is less or
equal to 30% predicted. Studies have shown
that patients treated with long acting
anticholinergic (e.g. tiotropium) have few er
exacerbations per year.

[ Q: 296 ] MRCPass - Respiratory

An 13 year old male has recent onset
breathlessness. He has a history of wheezing
particularly during the summer when the
pollen count is high.

Which of these tests would help to confirm the
diagnosis?

What is the best management procedure?

1- High dose oxygen

2- Intercostal drainage tube

3- Chemical pleurodesis

4- Aspiration of pneumothorax

5- Repeat chest x ray in 6 hours

Answer & Comments

Answer: 4- Aspiration of pneumothorax

Treatment of a pneumothorax of < 2 cm
margin would be initial aspiration.

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This is less painful, leads to a shorter duration
of admission, reduces the need for
pleurectomy.

[ Q: 298 ] MRCPass - Respiratory

A 65 year year old lady presents with
weight loss and haemoptysis and is admitted
to hospital. She has been a heavy smoker for
25 years. A Chest X ray shows a mass in the
right upper lobe.

Which is the best test to investigate at
present?

1- Sputum cytology

2- CT scan of the lung

3- Transbronchial biopsy

4- Lymph node biopsy

5- Pleural biopsy

Answer & Comments

Answer: 2- Horner's syndrome

An FEVi of < 1.1 L is a contraindication for
most cardiothoracic surgical procedures. A
malignant pleural effusion, distant
metastases, contralateral mediastinal lymph
node spread, vocal cord paralysis, phrenic
nerve paralysis, Horner's syndrome, and SVC
syndrome are contraindications to surgery in
lung cancer.

Left sided Horner's

Answer & Comments

Answer: 1- Sputum cytology

The mass seen on the CXR is likely to be a
malignancy in view of the history of smoking,
haemoptysis and weight loss. The initial test
should be sputum cytology, as the diagnosis
can be confirmed most easily. Staging CT scans
can then be done to guide further
management after this.

[ Q: 299 ] MRCPass - Respiratory

A 70 year old man has a diagnosis of
non small cell lung tumour, and has
completed a set of investigations.

Which one of the following is o
contraindication to lung surgery?

[ Q: 300 ] MRCPass - Respiratory

A 20 year old male presents with
breathlessness and wheezing.

Which of the following is most likely to suggest
asthma?

1- Increased serum IgE

2- Wheezing induced by smoking

3- Obstructive picture in the lung function
tests

4- Response to prednisolone

5- Diurnal PEFR variation > 20%

Answer & Comments

Answer: 5- Diurnal PEFR variation > 20%

1- FEVi of 1.7 L (50% predicted)

2- Horner's syndrome

3- History of myocardial infarction

4- Hypercalcaemia

5- Neuropathy affecting lower limbs

In asthma, diurnal PEFR variability is due to
various degrees of bronchial hyperreactivity.
This is the best indicator of likely asthma. A
raised IgE indicates atopy but is not diagnostic
of asthma.

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^ [ Q: 301 ] MRCPass - Respiratory

A -

# A 70 year old patient with COPD
presents with cough and breathlessness which
has worsened over 2 months.

On admission, he has the following arterial
blood gas results.

pH 7.32, p0 2 7 kPa, pC0 2 8 kPa, HC0 3 34
mmol/I, Base Excess -1.

Which one of the following biochemical states
fits best?

1- Chronic respiratory acidosis

2- Chronic respiratory alkalosis

3- Chronic metabolic acidosis

4- Chronic metabolic alkalosis

5- Acute metabolic acidosis

Answer & Comments

Answer: 1- Chronic respiratory acidosis

There is a mild respiratory acidosis (pH < 3.5
and pC02 > 6) and base excess is also not
elevated (in this case only -1). There is
metabolic compensation, as indicated by a
high bicarbonate ( >30). The patient's history
of COPD suggests that he has chronic hypoxia
and chronic C02 retention, hence causing the
picture of chronic respiratory acidosis.

[ Q: 302 ] MRCPass - Respiratory

«t -

* A breathless 35 year old woman has
the following lung function tests:

FEVi 1.2 L (65%)

FVC 1.4 L (60%)

FEVi/FVC ratio = 82%predicted

TLC = 65% predicted

RV = 60% predicted

TLCO = 57% predicted

KCO = 105% predicted

What is the most likely diagnosis?

1- COPD

2- Bronchiectasis

3- Cystic fibrosis

4- Scoliosis

5- Pneumonia

Answer & Comments

Answer: 4- Scoliosis

The lung function tests show a significant
restrictive defect. Only kyphoscoliosis or a
pneumonitis may fit this picture but given the
normal/high KCO (i.e. after correcting for
alveolar volumes), the most likely answer is
kyphoscoliosis as the gas exchange after
correcting for the alveolar volume is high.

[ Q: 303 ] MRCPass - Respiratory

fi -

# A 70 year old man presented with
shortness of breath. On examination, he had
the signs of a large right-sided pleural
effusion.

Investigations revealed: Pleural fluid analysis -
protein 65 g/L

What is the most likely cause?

1- Congestive cardiac failure

2- Nephrotic syndrome

3- Non specific pericarditis

4- Liver cirrhosis

5- Mesothelioma

Answer & Comments

Answer: 5- Mesothelioma

It is a case of exudative pleural effusion
(protein >30 g/l). Mesothelioma is the most
likely cause in this case. Other causes are:
malignancies, infection, autoimmune
conditions.

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[ Q: 304 ] MRCPass - Respiratory

A 75 year old man with COPD is on
long-term oxygen therapy (LTOT). He
complains of persistent leg swelling during a
routine review .

His ABG on a supplemental oxygen flow rate
of 2 l/min, shows:

pH of 7.35, pC0 2 of 5.7kPa, p0 2 of 7.8kPa and
HCO 3 of 28 mmHg

What should be done?

1- CXR

5- Serum precipitins

Answer & Comments

Answer: 4- High resolution CT of the chest

The diagnosis is likely to be pulmonary
fibrosis. The signs clubbing and inspiratory
crepitations suggest cryptogenic fibrosing
alveolitis. High resolution CT would show
reticular opacities or honeycomb changes if
there is pulmonary fibrosis. HRCT of the chest
shows basilar ground glass opacities as well as
linear and reticular opacities

2- Overnight oxygen saturation monitoring

3- Echocardiogram

4- Repeat ABG on air

5- CT scan of the chest

Answer & Comments

Answer: 2- Overnight oxygen saturation
monitoring

The presence of persistent oedema or
secondary polycythaemia suggests that the
correction of overnight Sa02 may be
inadequate. Nocturnal hypoxaemia may be
evident during an overnight Sa02 monitoring.

HRCT of the chest showing basilar ground
glass opacities as well as linear and reticular
opacities consistent with ^Pulmonary Fibrosis

•i j

[ Q: 306 ] MRCPass - Respiratory

[ Q: 305 ] MRCPass - Respiratory

A 40 year old man presented with

A 50 year man presents with a six

history

of recurrent Haemoptysis. He has

month history of cough and breathlessness.
On examination he has clubbing and there are
bilateral fine inspiratory crackles in the bases
of his lungs.

previously been treated for tuberculosis.
Chest x ray showed a rounded soft tissue mass
is seen within a cavity in the right upper lobe
with an air crescent.

A chest X ray reveals bilateral basal shadowing
in the lung fields. His blood gases reveal
hypoxia with a p0 2 of 9 kPa.

What is the best investigation to confirm a
diagnosis?

1- Lung function tests

2- Transbronchial biopsy

What is the diagnosis?

1- Chlamydia pneumonia

2- Caplan's syndrome

3- Extrinsic allergic alveolitis

4- Aspergilloma

5- Legionella infection

3- Serum ACE level

4- High resolution CT of the chest

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Answer & Comments

Answer: 4- Aspergilloma

Aspergillomas are masses of fungal mycelia
that grow in preexisting lung cavities.
Haemoptysis is a common symptom. They
may require treatment with either anti-
fungals or excision surgery if large. They are
not associated with bronchiectasis (unlike
allergic bronchopulmonary aspergillosis).

Aspergilloma

[ Q: 307 ] MRCPass - Respiratory

A 55 year old man who had two
episodes of hemorrhagic shock due to
intestinal hemorrhage and post-operative
secondary hemorrhage, was admitted to
intensive care unit.

During the following weeks this was followed
by bronchopneumonia with symptoms of
sepsis persisting over several weeks. Chest x
ray showed progressive changes in the
interstitial tissues and he became more
significantly hypoxic. Pulmonary capillary
wedge pressure was 13 mmHg.

Whot is the diagnosis?

1- Congestive cardiac failure

2- Pneumocystis pneumonia

3- Pulmonary embolism

4- Adult respiratory distress syndrome

5- Community acquired pneumonia

Answer & Comments

Answer: 4- Adult respiratory distress

syndrome

Respiratory distress syndrome is associated
with profound hypoxia and increased vascular
permeability (causing a V/Q mismatch). A
normal PCWP differentiates the condition
from pulmonary oedema. It does not respond
to steroids.

ARDS

[ Q: 308 ] MRCPass - Respiratory

A 40 year old man is HIV positive. He
presents with breathlessness to the hospital.
Chest XR shows bilateral interstitial lung
markings. His oxygen levels desaturate upon
mobilising.

Whot should be commenced?

1- Amoxycillin

2- Amoxycillin and clarithromycin

3- Iv co-trimoxazole

4- Doxycycline

5- Quadruple TB therapy

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Answer & Comments

Answer: 3- Iv co-trimoxazole

The diagnosis is PCP. Silver staining rather
than auramine should be done. Mortality is
10%. Iv co-trimoxazole or pentamidine can be
used. Desaturation is typical with exercise in
PCP. Other bacterial infections such as TB are
more common among Africans.

[ Q: 309 ] MRCPass - Respiratory

A 25 year old male with a 5 year long
history of bronchial asthma, presented with
worsening of asthma and fever of 20 days
duration. The patient was well controlled on
budesonide metered dose inhalations (400
pg/day) and rarely ever required to take
salbutamol inhalations.

For the past 20 days, the patient was
experiencing increasing breathlessness, fever,
cough and production of mucoid
expectoration for the past 20 days.

Examination a BP of 130/80 mmHg, and
temperature 38.2°C.

Respiratory examination revealed bilateral
widespread wheezes.

Investigations revealed- Hemoglobin- 12.4
g/dl, total white count - 13 x 10 9 /L,
Neutrophils 6 (2-7.5) x 10 9 /L, Lymphocytes 3
(1.3-3.5) x 10 9 /L, Eosinophils 4 (0.04-0.44) x
10 9 /L. Serum IgE was 800 (0-380) klU/ml.

The chest X-ray revealed pulmonary infiltrates
in the right mid and lower zones.

What is the likely diagnosis?

1- Chronic obstructive pulmonary disease

2- Allergic broncho pulmonary aspergillosis

3- Pulmonary embolus

4- Extrinsic allergic alveolitis

5- Mesothelioma

Answer & Comments

Answer: 2- Allergic broncho pulmonary
aspergillosis

ABPA usually occurs in association with
asthma, but can occur in cystic fibrosis. It is
treated with either oral or inhaled steroids.
There is some evidence supporting anti-fungal
agents like itraconazole, but amphotericin is
not used. IgG and IgE are raised. In addition
skin-testing or examination of sputum with
fungal stains can be used.

Sputum culture is not often helpful. ABPA can
lead to proximal bronchiectasis affecting the
upper lobes if left untreated.

CXR showing pulmonary infiltrates on the right

in ABPA

[ Q: 310 ] MRCPass - Respiratory

A 16 year girl with know n cystic
fibrosis presents with cough and fevers. Chest
X ray shows right lower zone consolidation.

What antibiotic should be commenced?

1- Amoxycillin

2- Metronidazole

3- Ceftazidime

4- Gentamicin

5- Piperacillin

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Answer & Comments

Answer: 3- Ceftazidime

Patients with cystic fibrosis often have
pseudomonas as a pathogenic infection.
Ceftazidime and ciprofloxacin would cover the
organism, and sometimes gentamicin or
meropenem may be required due to
resistance.

[ Q: 311 ] MRCPass - Respiratory

A 50 year old asthmatic treated with
high dose of inhaled corticosteroids develops
a skin rash. His routine blood tests shows mild
renal dysfunction and blood eosinophilia. His
chest radiograph is normal.

Which blood test should be done next?

1- Total Ig E level

2- Antineutrophil cytoplasmic antibodies

3- Anti GBM antibody

4- Aspergillus fumigates precipitins

5- Anti-nuclear antibody (ANA)

Answer & Comments

Answer: 2- Antineutrophil cytoplasmic

antibodies

Skin rash and renal dysfunction in an
asthmatic suggests Churg- Strauss syndrome.
Churg-Strauss syndrome, or allergic
granulomatous angiitis, is a rare syndrome
that affects small- to medium-sized arteries.

The presence of 4 or more criteria indicates a
high likelihood of Churg-Strauss syndrome.

These criteria are:

(1) asthma

(2) eosinophilia of more than 10% in
peripheral blood

(3) paranasal sinusitis

(4) pulmonary infiltrates (may be transient)

(5) histological proof of vasculitis with
extravascular eosinophils

(6) mononeuritis multiplex or
polyneuropathy.

Hypergammaglobulinemia, increased

immunoglobulin E (IgE) levels, rheumatoid
factor, and positive ANCA are usually present.

Pulmonary Infiltrates in Churg Strauss

syndrome

[ Q: 312 ] MRCPass - Respiratory

A 70 year old man with chronic
obstructive lung disease presents with a
cough, fevers and green sputum.

What is the antibiotic of choice?

1- Teichoplanin

2- Cefotaxime

3- Erythromycin

4- Amoxicillin

5- Ciprofloxacin

Answer & Comments

Answer: 4- Amoxicillin

In COPD, the 3 bacterial species account for
most isolates are : Haemophilus influenzae,
Streptococcus pneumoniae and Moraxella
cattarhalis. First line treatment should be with
amoxicillin, but if the patient is allergic, a
tetracycline should be used.

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^ [ Q: 313 ] MRCPass - Respiratory

tl -

# A 60 year old patient was involved in
a car accident and sustained multiple
fractures. He had been in ITU not long before
there was a suspicion of severe respiratory
distress syndrome.

Which of these would help to confirm the
diagnosis?

1- CT scan of the chest

2- Oesophageal manometry

3- Pulmonary capillary wedge pressure

4- Requirement for ventilatory support

5- Arterial blood gases

lesion. Out of the following causes , which is
most likely to cause a cavitating lung lesion?

1- Mesothelioma

2- Small cell lung carcinoma

3- Squamous cell lung carcinoma

4- Adenocarcinoma of the lung

5- Large cell carcinoma of the lung

Answer & Comments

Answer: 3- Squamous cell lung carcinoma

Squamous cell carcinoma accounts for
approximately one-third of all cases of
bronchogenic carcinomas.

Answer & Comments

Answer: 3- Pulmonary capillary wedge
pressure

Respiratory distress syndrome can be caused
by severe trauma, smoke inhalation, multiple
blood transfusions, drow ning and aspiration,
and drugs such as salicylates and narcotics.
Chest XR would show bilateral infiltrates, and
the presentation mimics heart failure. Hence
the best test would be PCWP, which would be
normal (<18mmHg).

ARDS

[ Q: 314 ] MRCPass - Respiratory

A 68 year old man with weight loss
has a chest x ray which shows a cavitating lung

Squamous cell carcinomas tend to form firm,
nonencapsulated, sharply circumscribed
masses located in the main, lobar or
segmental bronchi. Larger tumors often
outgrow their vascular supply and may have
central areas of hemorrhage, necrosis or
cavitation.

A cavitating carcinomatous lung lesion

[ Q: 315 ] MRCPass - Respiratory

A 45 year man has a long history of
productive cough. He had complained of
frequent chest infections.

Examination reveals bilateral inspiratory
crackles in the bases of the lungs and clubbing
of the fingers.

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Which of following treatments is likely to
reduce the frequency of exacerbations?

1- Prophylactic antibiotics

2- Inhaled corticosteroids

3- Oral corticosteroids

4- Postural drainage

5- Lung transplant

Answer & Comments

Answer: 4- Postural drainage

The patient has bronchiectasis, in which the
common complication is difficulty
expectorating, postural drainage of secretions
is helpful.

[ Q: 316 ] MRCPass - Respiratory

A 60 year old man, ex-smoker (20
pack-years), was admitted to the hospital
because of a prolonged fever of up to 38.5°C
over a period of 10 days, associated with a
progressively worsening shortness of breath, a
nonproductive cough, weakness, and fatigue.

The chest radiograph, showed consolidations
at the base of both lungs, prominent
interstitial markings in the middle lung fields,
and hazy infiltrates in the right upper lung
field.

A bronchoscopy was done and BAL fluid
analysis showed alveolitis with macrophages
of 65%, lymphocytes of 25%, and neutrophils
of 10%.

Which drug is most likely to be responsible?

1- Sulphasalazine

2- Penicillamine

3- Gold

The diagnosis is interstitial pneumonitis.
Methotrexate is associated with interstitial
pneumonitis. This is rare but a serious
complication. Diagnosis is based on the clinical
setting, clinical manifestations, radiographic
abnormalities, bronchoalveolar lavage (BAL),
and lung histology.

[ Q: 317 ] MRCPass - Respiratory

A 40 year old woman has a history of
cough with copious phlegm with intermittent
haemoptysis. She also gets recurrent chest
infections and has a long history of joint pains.
She is on non-steroidal anti-inflammatory
drugs.

Her chest radiograph shows linear
radioluciences at both bases. A high-
resolution computed tomography scan (HRCT)
of the chest confirms bronchiectasis.

What is the likely cause?

1- Old tuberculosis

2- Hypogammaglobulinaemia

3- Rheumatoid arthritis

4- Cystic fibrosis

5- Kartagener's syndrome

Answer & Comments

Answer: 3- Rheumatoid arthritis

The case scenario suggests rheumatoid
arthritis. 4 % of patients with rheumatoid
arthritis develop bronchiectasis. Other causes
are chronic infection (TB, measles, whooping
cough etc), foreign body aspiration,
hypogammaglobulinaemia, Kartagener's
syndrome, Young's syndrome, cystic fibrosis,
allergic bronchopulmonary aspergillosis.

4- Methotrexate

5- Azathioprine

Answer & Comments

Answer: 4- Methotrexate

[ Q: 318 ] MRCPass - Respiratory

A 35 year old lady has a headache,
cough and myalgia.

On examination, she has a pyrexia and
scattered crackles bilaterally on auscultation

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of the chest. Rapid cold agglutinins was
positive.

Whot is the likely diagnosis?

1- Tuberculosis

2- Staphylococcal pneumonia

3- Streptococcal pneumonia

4- Mycoplasma pneumonia

5- Legionella pneumonia

Answer & Comments

Answer: 4- Mycoplasma pneumonia

Mycoplasma pneumonia is the commonest
atypical pneumonia.

Approximately 15% of pneumonias in adults
are due to Mycoplasma pneumoniae.
Transmission occurs from person to person by
infected droplets. The incubation period is 9-
21 days. The incidence is higher during the
winter months. Fever, chills, cough and
headache are early symptoms. Dyspnoea,
chest pain and haemoptysis are rare.

Small pleural effusions may occur but are rare.
Cold agglutinins are usually present in a titre
greater than 1:32.

[ Q: 319 ] MRCPass - Respiratory

A 32 year old man is admitted to
hospital with a history of breathlessness of 4-6
weeks duration. He initially had flu-like
symptoms and was treated by his doctor with
a 5-day course of amoxicillin. How ever, he
then started coughing up blood, leading to
urgent referral.

On examination he was dyspnoeic at rest, with
bilateral crackles on auscultation of the lungs.

Investigation revealed anaemia and impaired
renal function (creatinine 250 micromol/l).
Pulmonary function tests were normal apart
from an abnormally high diffusion factor.
Urine dipstick testing showed the presence of
red blood cells.

Whot is the most likely diagnosis?

1- Goodpasture's syndrome

2- Farmer's lung

3- Invasive Aspergillosis

4- Extrinsic allergic alveolitis

5- Chronic eosinophilic pneumonia

Answer & Comments

Answer: 1- Goodpasture's syndrome

The clinical picture of pulmonary and renal
involvement is typical of Goodpasture's
syndrome. The condition is due to the
presence of circulating anti-glomerular
basement membrane antibodies (anti-GBM
antibodies. Other causes of pulmonary
haemorrhage and renal failure include
Wegener's granulomatosis, microscopic
polyangiitis and systemic lupus erythematous
(SLE).

[ Q: 320 ] MRCPass - Respiratory

A 40 year old lady presents with
breathlessness, hyperventilation and
tachycardia. She has a temperature of 38°C.
Over the last 5 days she had been
deteriorating with a cough and fever despite a
course of oral antibiotics, but her partner
mentions that she has become much worse
over the last day.

WCC is 18 x 10 9 /I

CRP is 220 mg/I

p0 2 is 6.5 kPa despite high flow 0 2

Pulmonary wedge pressure is 16mmHg

The chest X-ray shows bilateral interstitial lung
shadowing.

Whot is the likely diagnosis?

1- Pulmonary embolus

2- Pneumothorax

3- Severe pulmonary fibrosis

4- Pulmonary oedema

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5- Adult respiratory distress syndrome

Answer & Comments

Answer: 5- Adult respiratory distress

syndrome

ARDS can be precipitated by severe infection,
aspiration and illicit drug use. The main
differential is pulmonary oedema when the X-
ray shows bilateral interstitial lung field
shadowing. Pulmonary capilary wedge
pressure of < 19mmHg effectively excludes
left ventricular failure.

asthma was admitted to hospital for
reassessment of his recurring dry cough, chest
tightness and wheezing.

Investigations show:

Neutrophils 6 (2-7.5) x 10 9 /L

Lymphocytes 3 (1.3-3.5) x 10 9 /L

Eosinophils 9 (0.04-0.44) x 10 9 /L

CXR shows reticulonodular shadowing

Investigations to look for causes of the
eosinophilia (e.g., parasitosis,

immunodeficiency and malignant disease)
included stool microscopy, tumour marker
assays (for carcinoembryonic antigen and
cancer antigen (CA) 125, CA 19-9, CA 15-3 and
CA 72-4), mammography,

gastroduodenoscopy, bronchoscopy,

abdominopelvic ultrasonography, and vaginal
and pelvic examination; all yielded normal
findings.

Pulmonary function tests revealed a mild
obstructive and moderate restrictive pattern
[FEVi] 46%,[FVC] 55%, ratio of FEVi to FVC 72,
peak expiratory flow 53%, [DLCO] 46%.

What is the likely diagnosis?

1- Tuberculosis

2- Loeffler's syndrome

3- Sarcoidosis

4- Pulmonary embolism

5- Wegener's granulomatosis

Answer & Comments

Answer: 2- Loeffler's syndrome

Hypereosinophilic syndrome is a rare
condition where there is an idiopathic
eosinophil count of > 15 x 10 A 9/dl.

It is associated with Loeffler's syndrome which
is a transient pulmonary reaction with nodular
or reticular shadowing (diffuse, fanshaped
shadowing) on chest radiology and
eosinophilia.

Hypereosinophilic syndrome generally affects
young men ages 20-50. Thrombotic tendency,
neurological involvement (loss of intellect,
depressed mood and poor coordination) and
restrictive cardiomyopathy occur. There is
response to steroids.

The lung involvement results in nocturnal
cough, productive sputum, wheezing and
dyspnea, which raises the

suspicion of bronchial hyperreactivity.
Patients may be misdiagnosed as having
asthma. However, pulmonary function tests
typically reveal no airflow limitation.

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[ Q: 322 ] MRCPass - Respiratory

A 40 year old man has a history of
long standing cough with sputum production.
He also has recurrent episodes of chest
infections and sinusitis. He is married but has
been unsuccessful in having children. He also
has hearing difficulty.

Which one of the following is likely?

1- Hypogammaglobulinaemia

2- Alpha 1 antitrypsin deficiency

3- Defect in CFTR gene

4- Kartaganer's syndrome

5- Asthma variant

Answer & Comments

Answer: 4- Kartaganer's syndrome

Kartagener's syndrome is hereditary. It
comprises a triad of: situs inversus
(transposition) of the viscera, abnormal
frontal sinuses producing sinusitis and
bronchiectasis, and immobility of the cilia.

Symptoms and signs are dyspnoea, productive
cough, recurrent respiratory infections,
rheumatoid arthritis, renal abnormalities,
malformations of renal vessels and anomalous
subclavian artery. There is also otitis media,
nasal speech, conductive hearing loss,
anosmia or clubbing.

Dextrocardia in Kartagener's syndrome

[ Q: 323 ] MRCPass - Respiratory

A 40 year old woman is referred with
a history of red, painful legs of 3 weeks
duration that have not responded to a course
of flucloxacillin given for cellulitis. She is
afebrile, does not have any other symptoms,
and has never smoked. Examination reveals
tender purple / red nodules on her shins. A
chest radiograph shows prominent hilar
regions.

What is the appropriate management?

1- Lung Biopsy

2- Arrange CT scan of the lungs

3- Arrange bronchoscopy and bronchoalveolar
lavage to exclude malignancy

4- Start prednisolone

5- Arrange outpatients appointment for follow
up

Answer & Comments

Answer: 5- Arrange outpatients appointment
for follow up

The combination of bilateral hilar
lymphadenopathy and erythema nodosum is
diagnostic of sarcoidosis. This is usually self-
limiting. She should how ever be seen in
outpatients with full lung function tests
including transfer factor and lung volumes.
Serum angiotensin-converting enzyme (ACE)
level and lung functions can be used to
monitor disease. Worsening disease can be
treated with prednisolone.

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Sarcoidosis

[ Q: 324 ] MRCPass - Respiratory

A 50 year old patient has become
more breathless over several days. He was
assessed with a spectrum of tests. The chest X
ray was normal. In the interpretation of his
arterial blood gases on air the following
results were obtained:-

p0 2 : 8.0 kPa

pC0 2 : 9.2 kPa

pH: 7.40

Base Excess +2

What disease is likely to have caused this?

1- Community acquired pneumonia

2- Bronchiectasis

She describes episodes of cutaneous flushing,
which typically affects the head and neck. The
episodes are often associated with an
unpleasant warm feeling, itching feeling. They
last for half an hour.

She is slightly breathless but has had no
evidence of leg swelling or chest pain. She
smokes 10 cigarettes a day.

She has lost 3 kg of weight in the past two
months and has been experiencing night
sweats. A Chest x ray shows sail sign in the left
lower lobe, but no visible consolidation.

Which one of the following is the most likely
diagnosis?

1- Wegener's granulomatosis

2- Goodpasture's syndrome

3- Carcinoid tumour

4- Sarcoidosis

5- Tuberculosis

Answer & Comments

Answer: 3- Carcinoid tumour

A sail sign on the CXR indicates collapse of the
left lower lobe. The likely diagnosis is a
carcinoid tumour, which is associated with
smoking.

3- Tuberculosis

4- Guillain barre syndrome

5- Small cell carcinoma

Answer & Comments

Answer: 4- Guillain barre syndrome

The raised C02 and hypoxia demonstrate type
II respiratory failure. The causes of this could
be obstructive lung disease, neurogenic, or
musculoskeletal (kyphoscoliosis).

[ Q: 325 ] MRCPass - Respiratory

A 40 year lady presents with a 6
month history of intermittent haemoptysis.

An early and frequent (94%) symptom of
carcinoid tumors is cutaneous flushing, which
typically affects the head and neck. Episodes
are often associated with an unpleasant warm
feeling, itching, palpitation, upper-body
erythema and edema, salivation, diaphoresis,
lacrimation, and diarrhea. Exercise, stress, or
certain foods (eg, cheese) may trigger an
attack. Initial attacks are short, lasting only a
few minutes. With time, the duration
increases to hours. Flushes are reported to be
longest in association with bronchial
carcinoids.

Carcinoid tumours are neuroendocrine
tumours arising from Kultchitzsky cells. They
can be central or peripheral, and are classified

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as typical or atypical depending on their
histology. They are slow growing tumours of
lung with a peak incidence around age 40.
Bronchial obstruction is common. Diagnosis is
by bronchoscopy and biopsy.

Treatment is usually with lobectomy.

Sail sign (straight line around the heart

border)

[ Q: 326 ] MRCPass - Respiratory

A 68 year old man with emphysema
is referred to a chest clinic for consideration of
oxygen therapy. Despite maximal treatment
with bronchodilators, his exercise tolerance is
reduced to about 25 yards.

Physical examination and pulmonary function
test was consistent with emphysema. There
was no evidence of heart failure. ECG was
normal. CXR showed hyperinflated lung fields.

Oxygen saturation was 90%. ABG showed ph
of 7.36, pC0 2 of 3.7kPa, p0 2 of 7.6 kPa.

What should be recommended?

1- Overnight Sa0 2 monitoring

2- Course of steroids

3- Walking test with a trial of oxygen

4- Repeated ABG in 6 weeks time

5- Long-term oxygen therapy

This patient does not meet the criteria for
long term oxygen therapy, which is indicated
when the pa02 is persistently below 7.3 kPa
on air. Clinical stability is defined as the
absence of exacerbation of chronic lung
disease for the previous 5 weeks.

Patients without chronic hypoxaemia and not
on LTOT, should be considered for ambulatory
oxygen therapy if they show evidence of
exercise oxygen desaturation (a fall of Sa02 of
at least 4% below 90%), improvement in
exercise capacity with ambulatory oxygen
therapy and motivation to use the ambulatory
oxygen outside the house.

Assessment should be performed on both air
and supplemental oxygen with the patient
blinded as to the content of the cylinder.

[ Q: 327 ] MRCPass - Respiratory

A 50 year old woman presents with
breathlessness that has been getting gradually
worse over a few weeks and she has difficulty
mobilising. On physical examination she is
found to have a large left sided pleural
effusion.

The presence of the effusion is confirmed by
chest radiography.

The most appropriate initial investigation
would be:

1- Diagnostic aspiration of pleural fluid

2- Sputum cytology

3- CT chest

4- Pleural biopsy

5- Mantoux test

Answer & Comments

Answer: 1- Diagnostic aspiration of pleural
fluid

Answer & Comments

Answer: 3- Walking test with a trial of oxygen

The first investigation should be diagnostic
aspiration of pleural fluid.

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Light's criteria can be used to distinguish
transudates from exudates: in exudates at
least one of the following three criteria are
met:

pleural fluid protein concentration greater
than 50% of that in plasma;

pleural fluid LDH greater than 60% of that in
plasma;

pleural fluid LDH more that two thirds the
upper limit of normal in plasma

In general, if the protein is < 30 g then it is
considered to be a transudate, if > 30 g then it
is an exudate.

^ [ Q: 328 ] MRCPass - Respiratory

# A 38 year old man is admitted to the
hospital with a one-w eek history of dyspnoea.
He is HIV positive. His chest radiograph shows
bilateral alveolar infiltrates. The admitting
doctor makes a diagnosis of Pneumocystis
carinii pneumonia (PCP).

What treatment should be started?

1- AZT

2- IV metronidazole

3- IV co-trimoxazole

4- IV fluconazole

5- IV amphotericin

Pneumocystis pneumonia

[ Q: 329 ] MRCPass - Respiratory

A 40 year old man has a 3 month
history of cough, dyspnoea and sputum
production. He smokes 20 cigarettes a day and
has a history of asthma. There is no history of
asbestos exposure.

His WBC count is 24 x 10 9 /L with 70%
neutrophils and 3.0 x 10 9 /L (5%) eosinophils.
IgE level is elevated. He has decreased breath
sounds corresponding to parenchymal
infiltrates on the CXR.

Which is the best test to confirm the
diagnosis?

1- HIV test

Answer & Comments

Answer: 3- IV co-trimoxazole

PCP patients are usually hypoxic and chest
radiograph characteristically shows bilateral
alveolar infiltrates.

The patient should receive intravenous co-
trimoxazole in a dose of 120mg/kg for at least
3 weeks as well as glucocorticoids (IV
methylpred for 3 days). This, when used in
patients with moderate to severe hypoxia,
decreases the risk of respiratory failure and
death by over 50%.

2- Stool for ova,cysts,parasites

3- Autoimmune screen

4- Aspergillus precipitins

5- Sputum for Acid Fast Bacilli

Answer & Comments

Answer: 4- Aspergillus precipitins

The condition described is Allergic Broncho
Pulmonary Aspergillosis, commoner among
asthmatics and cystic fibrosis patients.
Wheeze, shortness of breath and productive
cough are symptoms.

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Allergic bronchopulmonary aspergillosis
results from an allergic reaction to Aspergillus
fumigatus which actually grow s in the walls of
the bronchi.

Eosinophilia and high IgE levels are suggestive
of the condition. Aspergillus precipitins (lab
test to detect antibodies) the diagnosis. The
chest radiograph often shows evidence of
proximal bronchiectasis.

[ Q: 331 ] MRCPass - Respiratory

A 50 year old lady has been
complaining of worsening difficulty
with breathing over the past year. She has
previously been diagnosed with a goitre. On
examination, she had marked stridor.

Which of the following is helpful in
investigating the extent of airways
obstruction?

[ Q: 330 ] MRCPass - Respiratory

A 55 year old woman is admitted
with a history of syncopal episodes and
breathlessness. There is no prior history of
recent travel.

On examination she looks distressed. Her
pulse rate is 120 beats per minute, blood
pressure 85/60, JVP is elevated by 5 cm.
Respiratory rate 26 per minute, there is a soft
systolic murmur at the left sternal edge.
Breath sounds are clear.

Investigations show : HB 12.4 g/dL, Blood
gases pH 7.42, PaC0 2 3.3 kPa, Pa0 2 8.5 kPa.

She was put on high flow oxygen and given
low molecular weight heparin.

The next step in management of this patient
should be:

1- High dose aspirin

2- Coronary angiography

3- Urgent CTPA and consider thrombolysis

4- Intravenous unfractionated heparin

5- VQ scan

Answer & Comments

Answer: 3- Urgent CTPA and consider
thrombolysis

The diagnosis massive central pulmonary
embolus as the patient is hypoxic and
hypotensive. The best management is to
obtain an urgent CTPA and then thrombolyse
if there are no contraindications (e.g. high risk
of bleeding).

1- FEVi

2- FVC

3- Residual volume

4- Flow volume loop

5- Functional residual capacity

Answer & Comments

Answer: 4- Flow volume loop

The flow volume loop is a graphic recording of
airflow during maximal respiration and
expiration at different lung volumes, and may
be affected in a characteristic way by
alterations in the airway resistance. Fixed
lesions cause plateaus in both the inspiratory
and expiratory limbs of the flow volume loop.

Variable intrathoracic lesions are
characterized by expiratory slowing and
flattening of the expiratory limb.

Hov

Flow Volume Loop showing airways
obstruction

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^ [ Q: 332 ] MRCPass - Respiratory

fi -

# A 60 year old lady has arthritic
changes on her hand joints of ulnar deviation
and Butonniere's defomirty. She has chronic
breathlessness.

Which of the following is a likely association?

1- Aspergillosis

2- Pulmonary fibrosis

3- Empyema

4- Lung carcinoma

5- Pulmonary emboli

Answer & Comments

Answer: 2- Pulmonary fibrosis

The pulmonary complications of rheumatoid
arthritis are :

pulmonary fibrosis (interstitial lung disease)

bronchiolitis obliterans with organizing
pneumonia

bronchiectasis

interstitial pneumonitis secondary to drugs

[ Q: 333 ] MRCPass - Respiratory

A 35 year old man has significant
wheezing and breathlessness. Recordings of
peak flows shows diurnal variation. He was
prescribed with salbutamol but continues to
have frequent wheezy episodes.

What is the next step in management?

1- Phosphodiesterase inhibitors

2- Leukotriene antagonists

3- Oral antibiotics

4- Inhaled corticosteroids

5- Oral steroids

Answer & Comments

Answer: 4- Inhaled corticosteroids

Diurnal PEFR variation points tow ards a
diagnosis of asthma. First line treatment are
short acting B agonists such as salbutamol and
Patients who do not respond to B agonists
should be treated with inhaled corticosteroids
(becotide or flixotide) which help to reduce
exacerbations in the long term.

^ [ Q: 334 ] MRCPass - Respiratory

/ -

# A 55 year old lady presents with

worsening breathlessness. She has a history of
Raynaud's phenomenon, heartburn and reflux.

On examination, the skin over her fingers is
tight and shiny. She has multiple
telangiectasia over her face and nail-fold
capillary loops are seen. Her investigations
show she has Anticentromere antibodies.

What respiratory complication may occur?

1- Churg Strauss syndrome

2- Metastatic adenocarcinoma

3- Pulmonary hypertension

4- Allergic bronchopulmonary aspergillosis

5- Mesothelioma

Answer & Comments

Answer: 3- Pulmonary hypertension

The patient has the clinical features of limited
cutaneous scleroderma (LcSScformerly CREST
syndrome). Anticentromere antibodies occur
in 70-80% of these patients. A significant
respiratory complication is pulmonary
hypertension. Treatment is with prostaglandin
analogues e.g. iloprost (intravenous infusions)
or bosentan (oral).

[ Q: 335 ] MRCPass - Respiratory

A 16 year old boy was brought to the
A&E with wheeze and extensive rash whilst
eating at a Chinese takeaway.

On examination, he had extensive wheezes in
his chest, stridor, as well as urticaria covering

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his upper and lower limbs. His BP is 82/50
mmHg.

What is the most likely diagnosis?

1- Cl Esterase Deficiency

2- Salmonella infection

3- Idiopathic urticaria

4- Asthma

5- Allergy

Answer & Comments

Answer: 5- Allergy

days of intravenous flucloxacillin and
cefotaxime therapy.

Total serum IgE titre was 1600 IU (normal
range, 0-180 IU) and the skin prick test was
positive for Aspergillus fumigatus.

What should he be treated with?

1- Praziquantel

2- Aciclovir

3- Itraconazole

4- Rifampicin

5- HAART

The scenario is consistent with a food allergy,
e.g. nuts, leading to an anaphylactic reaction.
The patient should be treated with
hydrocortisone (iv or im) as well as
chlorpheniramine.

[ Q: 336 ] MRCPass - Respiratory

A 40 year old man with pneumonia is
being examined.

Which one of the following positive
auscultatory signs is diagnostic of bronchial
breathing?

1- Rhonchi

2- Increased vocal resonance

3- Aegophony

4- Whispering pectoriloquy

5- Fine inspiratory crepitations

Answer & Comments

Answer: 4- Whispering pectoriloquy

Whispering pectoriloquy is a diagnostic sign
for bronchial breathing.

[ Q: 337 ] MRCPass - Respiratory

A 16 year old boy with previous
tuberculosis had a 7-day history of progressive
cough, wheeze and tachypnoea, despite 4

Answer & Comments

Answer: 3- Itraconazole

Allergic bronchopulmonary aspergillosis
(ABPA) is a diagnosis which can be confirmed
by significantly elevated serum IgE titre,
positive skinprick tests for aspergillus, positive
IgG aspergillus precipitins.

Treatment is with antifungals. Steroids may be
required in patients with respiratory distress.

[ Q: 338 ] MRCPass - Respiratory

A 35 year old man whose condition
has suddenly deteriorated is brought to A&E.
He had arrived 30 minutes earlier with a 2-
hour history of central pleuritic chest pain and
breathlessness. He collapsed while aw aiting
CXR.

He is cyanosed and has a pulse 130/min and
BP of 85/45 mmHg. Oxygen saturation is
reading 81%, despite high flow oxygen via a
re-breathe mask.

Respiratory examination reveals reduced
breath sounds in the right lung field with
deviation of the trachea tow ards the left.

What immediate course of action should be
taken?

1- Pleurodesis

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2- Insert large bore needle into right
hemithorax

3- Arrange for urgent portable chest XR

4- Check arterial blood gases and commence
BIPAP

5- Contact ITU to arrange for the patient to be
ventilated

Answer & Comments

Answer: 2- Insert large bore needle into right
hemithorax

The diagnosis is a right sided spontaneous
pneumothorax, which has now developed into
a tension pneumothorax.

As the patient is unstable, there is no time to
arrange for portable chest XR, insertion of a
large bore needle would reduce the pressure
in the right hemithorax.

Large right sided pneumothorax

^ [ Q: 339 ] MRCPass - Respiratory

/ -- 1 -

* A 45 year old man develops

breathlessness and a non productive cough.

He has mild fevers and has lost half a stone in

weight over the past six months. He has had

previously treated tuberculosis. He works as a

taxi driver.

Over the past ten years he and his partner
went fossil hunting in old quarries. Sputum
samples are AFB negative.

His chest X-ray shows nodular shadowing in
the upper zone.

What is the likely diagnosis?

1- Silicosis

2- Reactivation of TB

3- Cadmium lung

4- Histiocytosis X

5- Asbestosis

Answer & Comments

Answer: 1- Silicosis

Previous TB predisposes to silicosis, which can
present as fever, breathlessness and weight
loss. Coal miners, quarry workers and people
whose hobbies predispose to exposure to
silica are at risk.

Silicosis

^ [ Q: 340 ] MRCPass - Respiratory

/I -

# A 70 year retired sandblaster has
worsening symptoms of cough, wheeze and
breathlessness. He has been keeping parrots
for 15 years as a hobby.

Serum precipitins for M faeni are negative.

Chest X ray shows hyperinflated lungs.

His lung function tests show :

FEVi 1.8L (predicted 2.6)

FVC 3.0L (predicted 3.2)

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FEVi/FVC 60%

Which of the following is the likely diagnosis?

1- Silicosis

2- Chronic obstructive airways disease

3- Farmer's lung

4- Allergic bronchopulmonary aspergillosis

5- Pigeon fancier's lung

Answer & Comments

Answer: 2- Chronic obstructive airways
disease

The symptoms and findings clearly point out
tow ards pulmonary embolism (PE). As the
clinical probability of PE is high, measurement
of D-dimer should not be performed, since the
result would not alter the need for definitive
investigation. Measurement of D-dimer
should only be performed when the
probability of PE is low , when a normal value
would be taken as reassuring and further
investigation would not be pursued.

V/Q scan less likely to be unhelpful in view of
her asthma; hence a CT pulmonary angiogram
would be the imaging procedure of choice.

The lung function tests show an obstructive
picture (reduced FEVi/FVC ratio). Interestitial
lung diseases are more likely to cause a
restrictive picture on the lung function test.

[ Q: 341 ] MRCPass - Respiratory

A 60 year old asthmatic lady is
admitted with sudden onset left sided
pleuritic chest pain accompanied by shortness
of breath.

Arterial blood gases are as follows: pH of 7.30,
p0 2 of 7.5 kPa, and pC0 2 of 3.8 kPa.

Chest XR is normal. She is commenced on
oxygen.

What is the most appropriate immediate
action ?

1- Request a chest XR in expiration

2- Request D-dimer

3- Start low molecular weight heparin and
request CT pulmonary angiography

4- Start low molecular weight heparin and
request a V/Q scan

5- Broad spectrum antibiotics

Answer & Comments

Answer: 3- Start low molecular weight heparin
and request CT pulmonary angiography

[ Q: 342 ] MRCPass - Respiratory

A 65 year old man has had 5 kg
weight loss over 6 months. He is an ex smoker
of 25 cigarettes a day for 40 years and used to
work in a coal mine.

A Chest X ray shows a large right sided pleural
effusion and several pleural plaques in both
lung peripheries.

Pleural aspiration reveals an exudate with 42 g
of protein.

What investigation should be recommended?

1- Bronchoscopy

2- Lung function tests

3- Spiral CT of the chest

4- Thoracoscopy and biopsy

5- Sputum for AFB

Answer & Comments

Answer: 4- Thoracoscopy and biopsy

This patient probably has a malignant effusion
as demonstrated by the exudate from the
pleural effusion. As he is symptomatic, the
best option would be to drain the fluid as well
as confirm a diagnosis simultaneously.

A video assisted thoracoscopy would help to
do this. In this procedure, an illuminated tube
is inserted through a small incision made betw

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een the ribs. It allows the operator to visualize
structures inside the chest and to perform
simple procedures such as biopsy and nodule
excision.

[ Q: 343 ] MRCPass - Respiratory

A 65 year old man with a smoking
history of 50 a day for many years has been a
chest radiograph showing a lung mass. He is
presently waiting a bronchoscopy.

Which one of the following supports o
diagnosis of small cell lung cancer?

1- Disseminated intravascular coagulation

2- Hypertrophic pulmonary osteoarthropathy
(HPOA)

3- Syndrome of inappropriate antidiuretic
hormone secretion (SIADH)

4- Thrombocytosis

5- Hypercalcaemia

Answer & Comments

Answer: 3- Syndrome of inappropriate
antidiuretic hormone secretion (SIADH)

SIADH is most comonly seen with small cell
carcinoma rather than non-small cell
carcinoma. HPOA, hypercalcaemia without
bone metastasis is more common in
squamous cell carcinoma. DIC and
thrombocytosis are more common with
adenocarcinoma.

[ Q: 344 ] MRCPass - Respiratory

A 60 year old woman presents with a

6-month history of progressive shortness of
breath. Her past medical history is
unremarkable apart from Raynaud's syndrome
for which she takes a calcium channel blocker.

On examination she has telangiectasia.

Her chest radiograph shows clear lung fields,
prominent pulmonary arteries and mildly
enlarged heart. Spirometry is normal, but gas
transfer is reduced by 40% of predicted.

What is the most likely diagnosis?

1- Cor pulmonale

2- Pulmonary arterial hypertension

3- Sarcoidosis

4- Pulmonary emboli

5- Pulmonary oedema

Answer & Comments

Answer: 2- Pulmonary arterial hypertension

The patient is likely to have scleroderma from
the clinical history.

There is also associated pulmonary
hypertension which such patients are at risk
of.

[ Q: 345 ] MRCPass - Respiratory

A 75 year old lady is admitted with
an acute exacerbation of chronic obstructive
pulmonary disease (COPD). One hour after
admission she remains distressed with a
respiratory rate of 35 per minute and is
peripherally cyanosed. Repeated arterial
blood gases show a severe respiratory acidosis
with a pH of <7.2.

Which of the following treatments is
recommended?

1- Give intravenous infusion of aminophylline

2- Give intravenous hydrocortisone

3- Repeat bronchodilator therapy and arrange
repeat arterial gases

4- Arrange for noninvasive positive pressure
ventilation

5- High flow oxygen

Answer & Comments

Answer: 4- Arrange for noninvasive positive
pressure ventilation

Non invasive positive pressure ventilation
should be considered, especially in COPD
patients when there is a need for ventilatory

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assistance as indicated by worsening
dyspnoea, acute respiratory acidosis and
worsening oxygenation. If this does not work
then intubation and ventilation may be
necessary.

[ Q: 346 ] MRCPass - Respiratory

A 65 year old man presents with
inspiratory stridor. A chest X-ray showed
compression of the trachea by a retrosternal
goitre.

Which of the following investigations is the
most useful to assess the severity of his
airways obstruction ?

1- Flow volume loop

2- Forced expiratory volume

3- Forced vital capacity

4- Peak expiratory flow rate

5- Residual volume

Answer & Comments

Answer: 1- Flow volume loop

The flow volume loop is the best method of
assessing extent of obstruction associated
with a retrosternal mass.

Hov

Flow volume loop showing airways
obstruction

^ [ Q: 347 ] MRCPass - Respiratory

n -

* A 25 year old man who smokes, has
progressive breathlessness. He has had a long
history of recurrent chest infections. His lung
function tests show a FEVi/FVC ratio of 65%,
reduced FEVi, FVC and KCO of 45% predicted.
He also has an uncle who had a similar
presentation.

Which is the likely diagnosis?

1- Eosinophilic granuloma

2- Asthma

3- a 1 antitrypsin deficiency

4- Fibrosing alveolitis

5- Rheumatoid lung

Answer & Comments

Answer: 3- a 1 antitrypsin deficiency

a 1 antitrypsin deficiency is autosomal
recessive and causes an emphysematous
(obstructive picture) on the lung function
tests, with reduced transfer factor. The
phenotypes are M S or Z. ZZ has the worse
outcome.

Smoking cessation is essential.

Genotype

Prevalence

Reduction AAT
level (%)

0.1

0.03

[ Q: 348 ] MRCPass - Respiratory

«l -

# A 55 year old woman with
rheumatoid arthritis is referred with a history
of recurrent chest infections, intermittent
wheeze and production of half a teacupful of
sputum daily, on occasions with blood stained.

What is the most likely diagnosis?

1- Pulmonary fibrosis

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2- Bronchiectasis

3- Emphysema

4- Tuberculosis

5- Squamous lung carcinoma

The cherry red skin colour occurs when COHb
concentration exceeds 20% but it is rarely
seen in life. Pulse oximetry gives falsely high
oxygen saturation sand it is not
recommended.

Answer & Comments

Answer: 2- Bronchiectasis

Bronchiectasis is associated with rheumatoid
arthritis, occurring in 3-4% of patients with
this condition. As with all other causes of
bronchiectasis, it presents with recurrent
chest infections and excessive sputum.
Recurrent haemoptysis is a common feature.

[ Q: 349 ] MRCPass - Respiratory

A 38 year old man with a history of
depression is brought to the accident and
emergency department after being found
unconscious in a garage. A friend said that he
complained of a headache, then had nausea
and vomiting.

He then became unrousable.

Oxygen saturations are 95% on air and breath
sounds are clear on auscultation.

Whot is the likely diagnosis?

1- Pulmonary eosinophilia

2- Pulmonary embolus

3- Adult respiratory distress syndrome

4- Pneumocystis pneumonia

5- Carbon monoxide poisoning

Answer & Comments

Answer: 5- Carbon monoxide poisoning

Carbon monoxide poisoning is produced by
the incomplete combustion of carbon
containing fuels such as gas, coal, oil, wood
and coke.

Headache is the most common symptom
(90%) followed by nausea & vomiting, vertigo,
alteration in consciousness and weakness.

[ Q: 350 ] MRCPass - Respiratory

A 45 year man has breathlessness
and a dry cough. On examination, there are
bilateral basal crepitations in his lungs. Oxygen
saturations are 95% on air. Circulating
precipitins towards Micropolyspora faeni are
positive.

Whot is the likely diagnosis?

1- ABPA

2- Bagassosis

3- Farmer's lung

4- Bird fancier's lung

5- Cheese worker's lung

Answer & Comments

Answer: 3- Farmer's lung

This is a form of hypersensitivity pneumonitis.
Farmer's lung is caused by the actinomycetes
Micropolyspora faeni, and bagassosis is
caused by Thermoactinomyces sacchari.

[ Q: 351 ] MRCPass - Respiratory

A 45 year old man develops
breathlessness and a non productive cough.
He has mild fevers and has lost half a stone in
weight over the past six months. He has had
previously treated tuberculosis. He works as a
taxi driver.

Over the past ten years he and his partner
went fossil hunting in old quarries. Sputum
samples are AFB negative.

His chest X-ray shows nodular shadowing in
the upper zone.

Whot is the likely diagnosis?

1- Silicosis

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2- Cadmium lung

3- Histiocytosis X

4- Reactivation of TB

5- Asbestosis

Answer & Comments

Answer: 1- Silicosis

Previous TB predisposes to silicosis, which can
present as fever, breathlessness and weight
loss. Coal miners, quarry workers and people
whose hobbies predispose to exposure to
silica are at risk.

Silicosis - Mid and Upper Zone linear and
reticulonodular shadowing,

Answer & Comments

Answer: 2- Radiotherapy should be given to
prevent seeding of tumour cells

In mesothelioma no treatment has been
shown to influence the universally fatal
outcome. After obtaining a positive biopsy,
radiotherapy should be given in an attempt to
prevent seeding of tumour cells, around the
area of the biopsy.

^ [ Q: 353 ] MRCPass - Respiratory

# A 50 year old iv drug user has been
referred to the medical ward after being
brought in to casualty. He has a chronic cough
productive of sputum, loss of weight, and
night sweats. On examination he is unkempt
and emaciated. His trachea is deviated to the
left and there are crepitations over the apex
of the left lung.

CXR shows fibrosis and cavitation in the left
apex.

The investigation most likely to confirm the
diagnosis would be:

1- CT chest

[ Q: 352 ] MRCPass - Respiratory

A 70 year old man who has
previously worked in the building trade
presents with a history of chest pain and
dyspnoea. On examination he has evidence of
a right-sided pleural effusion. Pleural
aspiration is performed and a pleural biopsy
taken. Histology from the biopsy shows
mesothelioma.

What should be done?

1- The diagnosis should be queried

2- Radiotherapy should be given to prevent
seeding of tumour cells

3- Surgery

4- Chemotherapy should be given to prevent
seeding of tumour

5- Curative radiotherapy should be given

2- Gastric lavage

3- Sputum for acid and alcohol fast bacilli

4- Mantoux test

5- Fibreoptic bronchoscopy

Answer & Comments

Answer: 3- Sputum for acid and alcohol fast
bacilli

TB is likely. In a patient with a productive
cough, AFBs should be positive in the sputum.

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Red coloured AFB

[ Q: 354 ] MRCPass - Respiratory

A 55 year old smoker has a history of
breathlessness and a dry cough. He has
several nodules present in the perihilar region.
His serum calcium is normal. A bronchoscopy
and transbronchial biopsy is done. This shows
non necrotic granulomas and multinucleated
giant cells.

Which of the following is likely?

1- Histoplasmosis

2- Aspergillosis

3- Tuberculosis

4- Small cell carcinoma

5- Silicosis

Answer & Comments

Answer: 3- Tuberculosis

Multinucleated giant cells are very large
epidermis cells that have multiple nuclei. They
can be present in viral infections (e.g. herpes),
TB or lymphoma. Granulomatous disease
suggests either sarcoid, TB or Wegener's
granulomatosis.

A multinucleated giant cell

[ Q: 355 ] MRCPass - Respiratory

A 30 year old woman with epilepsy
has been diagnosed with pulmonary
tuberculosis and is about to be started on
quadruple therapy.

Which drug may cause urine discolouration?

1- Pyrazinamide

2- Erythromycin

3- Rifampicin

4- Isoniazid

5- Ethambutol

Answer & Comments

Answer: 3- Rifampicin

Discoloration of urine is due to rifampicin.
Rifampicin is a liver enzyme inducer but
isoniazid is an enzyme inhibitor.

Urine discolouration in a patient taking

Rifampicin

[ Q: 356 ] MRCPass - Respiratory

A 30 year old male patient presents
with worsening rhinitis, cough and wheezing,
which has occurred for the past 2 years. On
admission, his lung function tests show FEVi of
55% predicted and FVC of 65% predicted and
a chest X ray showed bilateral infiltrates.

He had an eosinophil count of 5 x 10 9 /L (0.04-
0.4) and sputum eosinophilia of 80% was also
found. There was also elevated IGE levels of
>1000 kU/L. Serum ANCA was positive at a
dilution of 1:1024.

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A nasal biopsy showed chronic inflammation,
with some areas suggestive of vasculitis, and
eosinophilic infiltration.

Which diagnosis is most likely?

1- COPD

2- Mesothelioma

3- Churg Strauss syndrome

4- Tuberculosis

5- Extrinsic allergic alveolitis

Answer & Comments

Answer: 3- Churg Strauss syndrome

There are many causes of pulmonary
symptoms with eosinophilia including
Loeffler's syndrome, Churg Strauss syndrome,
pulmonary eosinophilic syndrome and ABPA.
Extrinsic allergic alveolitis does not cause a
wheeze and also does not cause eosinophilia.

Churg-Strauss syndrome is an uncommon
condition characterised by asthma and blood
eosinophilia together with an eosinophilic
vasculitis. The initial phase of the disorder is
one of asthma and allergic rhinitis, often
followed by peripheral blood eosinophilia with
eosinophilic tissue disease. The vasculitic
phase that follows is life-threatening; how
ever, it can often be treated effectively with
immunosuppression. It is associated with
granuloma formation and vasculitis affecting
several organs e.g. skin, pericardium, kidney
and lung.

Serum eosinophilia and elevated IgE levels are
typical. Laboratory diagnosis is based on tissue
biopsy and the antineutrophil cytoplasmic
antibody (ANCA) test. About 25% of patients
have cANCA and about 50% have pANCA.

with haemoptysis. He had a chest X ray which
shows masses with air halo around them in
the upper zones. He has positive serum
precipitins.

What is the likely diagnosis?

1- tuberculosis

2- Aspergillosis

3- Actinomycosis

4- Extrinsic allergic alveolitis

5- Coal worker's lung

Answer & Comments

Answer: 2- Aspergillosis

The air halo sign is particularly associated with
the fungal infection aspergillosis, This may be
predisposed to by previous TB infection
leading to cavitation. The positive serum
precipitins are towards aspergillus.

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Aspergilloma

[ Q: 358 ] MRCPass - Respiratory

A 55 year lady has had a long history
of productive cough and shortness of breath.
She often coughs up whitish sputum and is
prone to chest infections. On examination her
temperature is 36° C, chest expansion is
reduced and there are bilateral wet
inspiratory crackles.

Which one of the following treatments is most
helpful?

1- Intravenous antibiotics

2- B agonist inhalers

3- Postural drainage

4- Morphine

5- Prednisolone

Answer & Comments

Answer: 3- Postural drainage

This lady has bronchiectasis. There is no
suggestion of a chest infection during this
episode of admission, hence postural drainage
is the best treatment option.

[ Q: 359 ] MRCPass - Respiratory

A 55 year old farmer has had
progressive breathlessness over the past 2
years. He presents with a severe episode of
dyspnea and productive cough which occurred
6 hours after he started working. He mentions
that these episodes are typical but today is
more severe. On admission, his O 2 saturations
are 94% on air.

CXR shows bilateral interstitial shadowing in
upper zones.

Which of the following is the most useful test?

1- Precipitins to aspergillus

2- Sputum for AFB

3- Kveim test

4- Precipitins to Micropolyspora faeni

5- Bronchoscopy

Answer & Comments

Answer: 4- Precipitins to Micropolyspora faeni

This patient is likely to have extrinsic allergic
alveolitis. The classic presentation of farmer's
lung results from inhalational exposure to
thermophilic Actinomyces species.

Patients with extrinsic allergic alveolitis may
present acutely with a flulike illness with
cough. They can also present subacutely with
recurrent pneumonia or chronically with
exertional dyspnea, productive cough, and
weight loss.

The onset of symptoms after acute exposure
is usually betw een 4 and 12 hours. Some
antigens provoke symptoms after repeated
exposure; these include bioaerosols of
microbial or animal antigens and a few
reactive chemicals.

Thermophilic actinomycetes species which can
cause EAA include Saccharopolyspora
rectivirgula (formerly Micropolyspora faeni),
Thermoactinomyces vulgaris,

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Thermoactinomyces viridis, and

Thermoactinomyces sacchari.

[ Q: 360 ] MRCPass - Respiratory

A 60 year old woman had a CXR
showing pulmonary fibrosis. Upon review , of
her drug history, which of the following drugs
might she hove been on in the post?

1- Clarithromycin

2- Amoxicillin

3- Busulphan

4- Omeprazole

5- Ciprofloxacin

Answer & Comments

Answer: 3- Busulphan

Busulphan, bleomycin, amiodarone and
nitrofurantoin are drugs which commonly
cause pulmonary fibrosis.

[ Q: 361 ] MRCPass - Respiratory

A 65 year old farmer has been
getting worsening breathlessness for the past
4 years. These symptoms occur during work
and are often worse for approximately 10
hours after. He is a non smoker.

An X-ray of the chest revealed intensified
interstitial lung markings and reticular changes
in the lower parts of the lung. He also had
raised serum precipitins to micropolyspora
faeni.

Whot is the diagnosis?

1- Tuberculosis

2- Wegener's granulomatosis

3- Churg Strauss syndrome

4- Extrinsic allergic alveolitis

5- Pulmonary eosinophilia

Answer & Comments

Answer: 4- Extrinsic allergic alveolitis

Extrinsic allergic alveolitis causes a
neutrophilia due to cell mediation but
eosinophil count is normal. Bronchoalveolar
lavage shows lymphocytes and mast cells.

EAA is a delayed hypersensitivity reaction
which may be immune complex (III) mediated
or cell mediated (type IV) in chronic disease.

In Extrinsic Allergic Alveolitis, the most
common antigens are thermophilic
actinomycetes and avian proteins, and the
most common diseases are farmer's lung and
bird fancier's lung. Precipitins to
micropolyspora faeni are seen in farmer's
lung. Upper zone fibrosis causes audible
crackles. Symptoms are typically of
breathlessness but not wheeze.

EAA causing upper zone fibrosis

[ Q: 362 ] MRCPass - Respiratory

A 22 year old woman has asthma for
which she is using her salbutamol inhaler two
or three times a day.

Whot should be the next step in her
monogementifshe worsens?

1- Advise her to use the salbutamol inhaler
regularly three times a day

2- Add regular inhaled steroid, e.g.
beclometasone 100 microg twice daily

3- Add regular salmeterol twice daily

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4- Add regular inhaled steroid, e.g.

beclometasone 1000 microg twice daily

5- Add regular inhaled steroid, e.g.

beclometasone 1000 microg twice daily,
plus regular long-acting inhaled beta
agonist

Answer & Comments

Answer: 2- Add regular inhaled steroid, e.g.
beclometasone 100 microg twice daily

The British Thoracic Society Asthma guidelines
are as follows:

Step 1: PRN use of inhaled short-acting beta
agonists

Step 2: regular inhaled steroids

Step 3: high-dose inhaled steroids, or low -
dose inhaled steroids plus long-acting beta
agonist

Step 4: high-dose inhaled steroid and regular
bronchodilators (sustained release
theophylline, inhaled ipatropium, oral long-
acting beta agonist, high-dose inhaled
bronchodilators, cromoglycate / nedocromil)
Step 5: addition of regular steroid tablets

[ Q: 363 ] MRCPass - Respiratory

A 60 year old woman with know n
COPD is referred with a 4-month history of
morning headaches. She describes a dull
headache which is generalised, worst upon
waking up. She has home nebuliser
(salbutamol and atrovent) but is not on home
oxygen.

A routine arterial blood gas on admission
showed a pH of 7.34 pC02 of 6.2 kPa, p02 of
8.8 kPa and HCO3 30 mmHg.

What should be done?

1- Long-term oxygen therapy

2- Ambulatory oxygen therapy

3- CT chest

4- Overnight Sa02 and CO 2 monitoring

5- Repeat ABG

Answer & Comments

Answer: 4- Overnight Sa02 and C02
monitoring

Morning headaches are often ascribed to
patients with nocturnal hypoxia or early
morning hypercapnia. They are often
associated with sleep apnea or a chronic
respiratory disease such as COPD.

The admission blood gases show mild hypoxia,
and hypercapnia. There is respiratory acidosis
with metabolic compensation. It suggests that
there is a high likelihood of chronic hypoxia.

If oxygen monitoring confirmed nocturnal
hypoxia (defined as 02 sats of < 90% for more
than 30% of sleep time), she may require
nocturnal oxygen supplementation.

^ [ Q: 364 ] MRCPass - Respiratory

# A couple attend the GP surgery with
their 2 year old daughter. She has a history of
repeated chest infections, failure to thrive,
and steatorrhoea (fatty stools). They also have
an 8 year old child who is fit and well.

What is the likely diagnosis?

1- Pulmonary Eosinophilia

2- Asthma

3- Cystic fibrosis

4- Congenital Tuberculosis

5- Bochdalek Hernia

Answer & Comments

Answer: 3- Cystic fibrosis

The gene defect in cystic fibrosis is in a
mutation on chromosome 7. The inheritance
is autosomal recessive so the other child
without symptoms has not inherited two CF
genes. Pulmonary disease develops over a few
months after birth. Common infective

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organisms are pneumoccocus, Haemophilus
influenzae and Pseudomonas aeruginosa.

[ Q: 365 ] MRCPass - Respiratory

A 45 year old man complains of
wheeziness which is worse. He has a history of
asthma. His current medication consists of a
low dose of inhaled corticosteroids and
inhaled short-acting beta 2 agonist taken
three to four times a day.

Whot should be done next?

1- Add oral steroids

2- Add an inhaled long-acting beta 2 agonist

3- Add a long-acting anticholinergic

4- Add a short acting anticholinergic

5- Add a leucotriene receptor antagonist

2- Streptococcus pneumoniae, Klebsiella
pneumoniae, E coli

3- Streptococcus pneumoniae, Haemophilus
influenzae, Moxarella catarrhalis

4- Streptococcus pneumoniae, Pseudomonas
aeruginosa, Staphylococcus aureus

5- Streptococcus pneumoniae, Haemophilus
influenzae, Legionella pneumophilia

Answer & Comments

Answer: 3- Streptococcus pneumoniae,
Haemophilus influenzae, Moxarella catarrhalis

In infective exacerbations of COPD,
Streptococcus pneumoniae and Haemophilus
influenzae, as well as Moraxella are the
commonest organisms.

Answer & Comments

Answer: 2- Add an inhaled long-acting beta 2
agonist

According to the British Thoracic Society
guidelines the next step would be to add an
inhaled long-acting beta 2 agonist (LABA) and
then assess the situation. If there is a good
response to LABA, this medication should be
continued. If there is benefit from LABA but
control is still inadequate, LABA should be
continued, and the inhaled corticosteroids
should be increased to a high dose.

[ Q: 366 ] MRCPass - Respiratory

A 65 year old heavy smoker is
admitted with a history of increasing
breathlessness. This has been precipitated by
the development of a cough with yellow
purulent sputum.

The organisms that are likely to cause infective
exacerbations of COPD are:

[ Q: 367 ] MRCPass - Respiratory

A 65 year old man has longstanding
breathlessness on exertion. He has been
smoking 20 cigarettes a day over a period of
30 years.

On examination, the patient is breathless with
use of accessory muscles and resting
activation of the abdominal muscles. The
chest is barrel shaped.

With regards to this case , which one of the
following is known to be a predictor of
mortality?

1- Spirometry

2- Fibrotic changes

3- Body Mass Index

4- Arterial blood gases

5- How many cigarettes were smoked

Answer & Comments

Answer: 3- Body Mass Index

1- Streptococcus pneumoniae, Legionella
pneumophilia, Mycoplasma pneumoniae

A low body mass index is a known predictor of
mortality in patients with chronic obstructive
pulmonary disease.

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^ [ Q: 368 ] MRCPass - Respiratory

f | -

* A 40 year man presents with
shortness of breath. On admission he is unw
ell and has a respiratory rate of 32 breaths per
minute. His chest is wheezy on auscultation.

Arterial blood gases show :

p0 2 9.5 kPa, pC0 2 3.5 kPa, pH 7.48, HC0 3 25,
BE+2.

What is the likely clinical scenario?

1- Lactic acidosis secondary to metformin

2- Anxiety disorder

3- Asthma attack

4- Chronic bronchitis

5- Pneumothorax

Answer & Comments

Answer: 3- Asthma attack

The patient has a respiratory alkalosis (pH >
7.45) which is acute since the bicarbonate
levels are normal (22-28). There is hypoxia and
the patient is hyperventilating in response and
blowing off C02.

This would be consistent with an asthma
attack.

In an anxiety attack, hypoxia would not be
present.

[ Q: 369 ] MRCPass - Respiratory

A 30 year old man is admitted with a
history of haemoptysis, cough and dyspnoea.
He has been previously fit and has smoked 25
cigarettes a day for the last 10 years. A chest
XR shows diffuse alveolar infiltrates. He has a
microcytic, hypochromic anaemia, urine
dipstick confirms haematuria and proteinuria.
His lung function tests shows a normal
spirometry and a TLCO of 125% predicted.

3- Goodpasture's syndrome

4- Pulmonary tuberculosis

5- Pneumonia

Answer & Comments

Answer: 3- Goodpasture's syndrome

Goodpasture's syndrome is characterised by
diffuse alveolar haemorrhage and
glomerulitis. Men are commonly affected with
most cases occurring betw een the ages of 20-
30 years. It is more likely to occur in smokers.
The anti glomerular basement antibody (Anti-
GBM) is present in up to 90% of the patients.
Renal histology usually shows a focal
segmental necrotizing glomerulitis with
crescent formation. The TLCO is increased
during active bleeding and can be used to
monitor disease activity. An increase above
30% of baseline is suggestive of an intra-
alveolar bleed.

[ Q: 370 ] MRCPass - Respiratory

f -

# A 60 year old man presents with
sever breathlessness following an upper
respiratory tract infection.

Which of the following would support a
diagnosis of acute respiratory distress
syndrome (ARDS)?

1- High protein content of pulmonary oedema
fluid

2- Normal chest Xray

3- High pulmonary capillary wedge pressure

4- Increased lung compliance

5- High C0 2 levels

Answer & Comments

Answer: 1- High protein content of pulmonary
oedema fluid

What is the most likely diagnosis?

1- Pulmonary emboli

2- Chest trauma

Acute respiratory distress syndrome is
characterised by hypoxaemia, reduced lung
compliance, pulmonary hypertension and

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pulmonary infiltrates on chest X ray. There is
damage to the capillary endothelial cell linings
resulting in oedema leakage of proteins cells
into interstitial alveolar spaces.

A high pulmonary capillary wedge pressure
suggests heart failure. High C02 reflect type II
respiratory failure and are non specific.

[ Q: 371 ] MRCPass - Respiratory

A 60 year old man had a
transbronchial biopsy confirming squamous
cell carcinoma of the lung.

Which of the following is a contraindication
tow ards surgical resection?

1- Hypercalcaemia

2- Superior vena caval obstruction

3- Previous radiotherapy

4- Metastasis to local lymph nodes

5- Pleural effusion

Answer & Comments

Answer: 2- Superior vena caval obstruction

Extensive nodal spread, distal metastases,
stage NIB or more, and superior vena caval
obstruction are contraindications tow ards
surgery for lung cancer.

Answer & Comments

Answer: 2- Chronic obstructive lung disease

There is evidence for a small reduction in
mortality in patients with COPD and resting
hypoxia. Although indications for LTOT are
largely based on mortality data, some studies
have also suggested improvements in other
outcome measures, including depression,
cognitive function, quality of life, exercise
capability, and frequency of hospitalisation.

[ Q: 373 ] MRCPass - Respiratory

A 50 year
finding

old woman has an
of raised left

incidental

hemidiaphragm on the CXR. She has had no
history of cardiothoracic surgery or trauma to
the chest.

What is the likely diagnosis?

1- Vagus nerve palsy

2- Horner's syndrome

3- Hiatus hernia

4- Phrenic nerve palsy

5- Hepatomegaly

Answer & Comments

Answer: 4- Phrenic nerve palsy

[ Q: 372 ] MRCPass - Respiratory

In which of the following have
randomised controlled trials shown that long¬
term oxygen therapy (LTOT) reduces
mortality?

1- Asthma

2- Chronic obstructive lung disease

3- Cryptogenic fibrosing alveolitis

4- Cystic fibrosis

5- Pulmonary sarcoidosis

Causes of phrenic nerve palsy are :

■ pneumonia

■ pleurisy

■ aortic aneurysm

■ substernal goiter

■ neoplasms

■ thoracic surgery

■ herpes zoster infection

■ vasculitis
diabetes

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Raised Left hemidiaphragm

When is LTOTindicated?

1- p02 <7.2 kPa

2- p0 2 <7.8 kPa

3- p0 2 <8 kPa

4- p0 2 <8.5 kPa

5- p0 2 <9 kPa

Answer & Comments

Answer: 1- P02 <7.2 kPa

[ Q: 374 ] MRCPass - Respiratory

A 35 year old man has symptoms of
wheezing and has been diagnosed as having
late onset asthma. How ever, his GP measured
routine blood tests and found that he had a
creatinine of 250 umol/l.

Whot antibody is likely to be helpful in
confirming the diagnosis?

1- Antinuclear antibody

2- Anti phospholipids antibody

When there is polycythaemia or pulmonary
hypertension, Long Term Oxygen Therapy is
indicated when p02 < 8kPa. In uncomplicated
COPD, it is indicated when p02 < 7.2kPa

[ Q: 376 ] MRCPass - Respiratory

A 60 year old woman with asthma
presents with a history of acute
breathlessness and pleuritic chest pain. Her
arterial blood gases show the following
readings:

3- Anti Ro antibody

4- Anti nuclear cytoplasmic antibody

5- Anti gliadin antibody

pH 7.35, p0 2 6.8 kPa, pC0 2 4 kPa, bicarbonate
25 mmol/L

Which test is most specific to acute pulmonary
embolism?

Answer & Comments

Answer: 4- Anti nuclear cytoplasmic antibody

The clinical diagnosis is likely to be an ANCA
positive small vessel vasculitis such as
polyarteritis nodosa, as there is pulmonary
and renal involvement. Churg Strauss
syndrome should also be considered (only a
small proportion of patients with Churg
Strauss have a positive ANCA)

1- MRI of the chest

2- CT pulmonary angiogram

3- Chest x-ray

4- D-Dimers

5- V/Q scan

Answer & Comments

Answer: 2- CT pulmonary angiogram

[ Q: 375 ] MRCPass - Respiratory

A 60 year old man has a long history
of smoking and COPD. His resting p0 2 is 7.2
kPa and his continues to be breathless despite
being on home nebulisers. He is assessed for
long term oxygen therapy (LTOT).

Most of the tests are helpful but a CT
pulmonary angiogram remains the gold
standard diagnostic test for pulmonary
embolism.

[ Q: 377 ] MRCPass - Respiratory
A 35 year old man presents with

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swelling of his lips and around the throat
following consumption of prawns. His

investigations show:

serum IgE 150 kU/L (0-120)

C3 level is 77 mg/dL (65-190)

C4 level is 45 mg/dL (15-50)

Which of the following diagnosis is likely?

1- Cl esterase inhibitor deficiency

2- Allergic reaction

3- Systemic mastocytosis

4- Moon face

5- Cellulitis

Answer & Comments

Answer: 2- Allergic reaction

Which one of the following diagnosis is likely?

1- Aspergilloma

2- Guillain-Barre syndrome

3- Cryptogenic fibrosing alveolitis

4- Asthma

5- Congestive cardiac failure

Answer & Comments

Answer: 3- Cryptogenic fibrosing alveolitis

A reduced FVC, with normal FEVi, FEVi% and
PEF usually indicates restriction of lung
volume . KCO (transfer factor) is also reduced
in fibrotic lung disease, as in this case. The
additional findings of inspirational crackles
and clubbing suggests the diagnosis of
cryptogenic fibrosing alveolitis.

Mildly elevated IgE concentration suggests an
allergic reaction to praw ns. In angioneurotic
oedema due to Cl esterase inhibitor
deficiency, a low C4 with normal C3 level is
seen (C2 is also low but not commonly
measured).

[ Q: 378 ] MRCPass - Respiratory

A 40 year old man has with a 2 year
history of increasing shortness of breath. This
is worse with exertion e.g. climbing the stairs
at home and is even slightly so at rest. He is a
non-smoker.

On examination, his pulse is 95 beats/min and
his blood pressure is 140/95 mmHg. He has
finger clubbing and a crackling noise at the
end of inspiration over the bases of the lungs.
There was no ankle oedema Lung function
tests show :

FVC 2.5 I (predicted 3.2 )

FEVi 2.11 (predicted 2.4)

FEVi % 76% (predicted 75%)

Diffusing Capacity: Gas Transfer Factor for
carbon monoxide: DLCO 17 ml/min/mmHg
(predicted) 25

[ Q: 379 ] MRCPass - Respiratory

A 60 year old man has severe COPD
requiring home nebulisers and home oxygen.
He is admitted with an infective exacerbation.

Which of the following results would be
expected on the arterial blood gases?

1- PH 7.25 paC0 2 7 pa0 2 7.5 HCOs 30

2- PH 7.10 paC0 2 7 pa0 2 4 HCOs 24

3- PH 7.30 paC0 2 4 pa0 2 8.5 HC0 3 30

4- PH 7.40 paC0 2 4 pa0 2 4 HC0 3 22

5- PH 7.45 paC0 2 3 pa0 2 12 HC0 3 24

Answer & Comments

Answer: 1- PH 7.25 paC02 7 pa02 7.5 HC03
30

A long standing COPD patient would be
expected to have a high bicarbonate. However
this patient is unwell with type II respiratory
failure (high C02) and hence has
uncompensated respiratory acidosis.

[ Q: 380 ] MRCPass - Respiratory

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A 60 year old miner has been in the
occupation for 20 years. He presents with a
cough and breathlessness.

Chest XR shows diffuse interstitial shadowing.
A sputum sample is positive for acid fast
bacilli.

Which of the following dusts is most likely to
have predisposed the patient to tuberculosis?

1- Beryllium

2- Cadmium

3- Coal

4- Silica

5- House dust

Answer & Comments

Answer: 4- Silica

Slate workers, stonemasons and miners are
exposed to silica dust. Silicosis impairs
macrophage function, and in particular,
predisposes to TB infection.

[ Q: 381 ] MRCPass - Respiratory

A 34-year-old woman presented
with a dry cough, thorax constriction, and
generalised weakness. During the preceding 5
months, she had experienced these dry cough
episodes tw ice a week. A lung function test
showed a restriction of the vital capacity (71%
of the adjusted reference value), and the
diffusion capacity was also reduced (66 to
68 %).

Bronchoalveolar lavage specimens were
obtained, the lymphocytes were increased up
to 41% (norm, <10%), and neutrophils were
increased up to 6% (norm, <2%) with a normal
total cell count.

What is the likely diagnosis?

1- Asthma

2- Pulmonary embolus

3- Tuberculosis

4- Extrinsic allergic alveolitis

5- Alpha 1 antitrypsin deficiency

Answer & Comments

Answer: 4- Extrinsic allergic alveolitis

Extrinsic Allergic Alveolitis is a type III or type
IV response. There is no eosinophilia. IgG and
lymphocytes are involved in immune
response. Antigens of micropolyspora faeni
and thermoactinomyces are 0.5-5 microns .
These antigens which may be detected as
serum precipitins.

The acute form takes about 6 hours for
sensitisation to the inhaled antigen. The
chronic form may take weeks.

[ Q: 382 ] MRCPass - Respiratory

A 65 year old patient with COPD is
on maximal treatment.

Which one of the following is likely to prevent
further disease progression?

1- Steroids

2- Beta agonist inhalers

3- Stopping smoking

4- Tiotropium

5- Home oxygen

Answer & Comments

Answer: 3- Stopping smoking

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In COPD, discontinuation of smoking is the
only features which has been shown to reduce
disease progression.

[ Q: 383 ] MRCPass - Respiratory

*tj

A 60 year old male smoker has

emphysema.

His lung function tests show :

FEVi is 0.5 (20% predicted)

FVC is 2.2 (61% predicted)

FEVi:FVC ratio of 26%

His arterial blood gases show a p0 2 of 7.5 and
7.2 on two separate occasions. He is mildly
breathless at rest, but severely breathless on
exertion.

Whot is the best measure of his respiratory
function?

1- TLCO

2 - FEVi

3- FVC

4- KCO

5- TLC

Answer & Comments

Answer: 2- FEVi

The breathlessness worsens considerably
without much change in oxygen tension,
suggesting that the cause of his dyspnoea is
hyperinflation of his chest which worsens on
exertion.

Severity of emphysema is defined by the
British Thoracic Society (BTS) in relation to
FEVi, not FEVi:FVC ratio. Mild is 60-80%
predicted; moderate 40-60% and severe
<40%.

[ Q: 384 ] MRCPass - Respiratory
A 40 year old lady was admitted to

hospital with fevers and cough productive of
sputum.

Chest X-ray shows diffuse patchy
consolidation around the left lung. She has
had a flu like illnes 4 weeks ago, and has a past
medical history of asthma. She also smokes 10
cigarettes a day.

Which organism is likely to be responsible?

1- Mycoplasma

2- Pseudomonas

3- Klebsiella

4- Staphylococcus

5- Tuberculosis

Answer & Comments

Answer: 4- Staphylococcus

Following a viral infection, patients are
predisposed to staphylococcal infection. The
chest XR changes suggest staphlococcus
rather than streptococcus (which would cause
lobar consolidation).

[ Q: 385 ] MRCPass - Respiratory

• X

A 50 year old man presents with a 3
month history of cough and breathlessness.
He was apyrexial on admission.

His blood show ESR 60 mm/hr, urea 7 pmol/l,
creatinine 100 pmol/l, sodium 137 mmol/I,
potassium 4.1 mmol/l, corrected calcium 2.75
(2.2-2.7) mmol/l, phosphate 0.82 (0.8-

1.4)mmol/l.

Chest X ray shows bilateral hilar
lymphadenopathy and eggshell calcification.

What is the likely diagnosis?

1- Extrinsic allergic alveolitis

2- Tuberculosis

3- Sarcoidosis

4- Allergic bronchopulmonary aspergillosis

5- Leiomyoma

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Answer & Comments

Answer: 3- Sarcoidosis

Sarcoidosis can cause many changes on the
CXR. Among these are unilateral or bilateral
hilar lymphadenopathy, diffuse parenchymal
changes, eggshell calcification, pleural
effusions and nodules.

Bilateral hilar lymphadenopathy in sarcoidosis

[ Q: 386 ] MRCPass - Respiratory

A 40 year old woman presents with
breathlessness, cough and fever. On
examination, she has basal crackles in the lung
fields. Circulating precipitans to
Micropolyspora faeni are positive.

Which of the following is the most likely
diagnosis?

1- Pigeon fanciers' lung

The classic presentation of farmer's lung
results from inhalational exposure to
thermophilic Actinomyces species and
occasionally from exposure to various
Aspergillus species.

Acute farmer's lung develops after large
exposure to moldy hay or contaminated
compost. Symptoms often spontaneously
resolve within 12 hours to days if antigen
exposure is eliminated or avoided. It manifests
as new onset of fever, chills, nonproductive
cough, chest tightness, dyspnea, headache,
and malaise.

[ Q: 387 ] MRCPass - Respiratory

A 50 year old meat factory worker
has been unw ell with fever, cough, sweats
and lethargy. On examination, he had a
purpuric rash and hepatosplenomegaly.

What is the likely diagnosis?

1- Pulmonary embolism

2- Respiratory syncytial viral pneumonia

3- Streptococcal pneumonia

4- Q fever pneumonia

5- Aspergilloma

Answer & Comments

Answer: 4- Q fever pneumonia

2- Allergic Bronchopulmonary Aspergillosis

3- Farmers' lung

4- PCP infection

5- Pulmonary fibrosis

Answer & Comments

Answer: 3- Farmers' lung

Farmer's lung is the most common type of
hypersensitivity pneumonitis. Hypersensitivity
pneumonitis, also known as extrinsic allergic
alveolitis, is associated with intense or
repeated exposure to inhaled biologic dusts.

Q fever is due to Coxiella burnetii and is
acquired via animal contact. It can occur in
outbreaks in farming communities and in
abbatoirs. Treatment is with prolonged
courses of tetracyclines. Rarely infection can
be persistent leading to chronic symptoms
including fatigue, malaise and sweats.
Hepatitis, hepatosplenomegaly,

maculopapular rash and endocarditis are
associated.

[ Q: 388 ] MRCPass - Respiratory

A 50 year old woman, is admitted
with malaise and fever. Four weeks previously

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she had suffered a chest infection for which
she was given a course of oral amoxycillin. She
felt better initially, but is now getting worse,
complaining of intermittent fevers. Her chest
radiograph shows a left sided pleural effusion.

An aspirate shows fluid with a protein of 42 g
and pH of 7.0.

The most likely diagnosis is:

1- Collapse of the left lung

2- Empyema

3- Serous pleural effusion

4- Fibrotic lung disease

5- Tuberculosis

Answer & Comments

Answer: 2- Empyema

The likely cause is a pneumonia which has not
resolved, leading to empyema. Examination of
a pleural aspirate (microscopy for organisms,
culture). A protein level >30g would be
consistent with an exudate and a pH of < 7.2 is
suggestive of infection.

Empyema (air fluid level)

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[ Q: 389 ] MRCPass - Nephrology

A 32 year old diabetic man has
chronic renal failure and has on peritoneal
dialysis for a few years. He is currently on 1-
alfa-calcidol replacement. His calcium is 3
mmol/l, phosphate 0.6 (0.8-1.4) mmol/l and
PTH is 9 (0.8-9.0) pmol/l.

Which of the following is the diagnosis?

1- Hypercalcaemia secondary to vitamin D
replacement

2- Primary hyperparathyroidism

3- Secondary hyperparathyroidism

4- Tertiary hyperparathyroidism

5- Normal finding in a dialysis patient

Answer & Comments

Answer: 4- Tertiary hyperparathyroidism

Secondary hyperparathyroidism occurs in
renal failure because of hypocalcaemia due to
lack of 1 hydroxylation of 25(OH)Vit D.
Tertiary hyperparathyroidism is due to
longstanding secondary hyperparathyroidism.
Despite Vit D replacement to treat secondary
hyperparathyroidism, the parathyroid glands
continue to secrete lots of PTH. Treatment
should therefore be to remove the
parathyroid glands surgically.

[ Q: 390 ] MRCPass - Nephrology

A 55 year old man with a history of
hypertension has renal impairment. His
creatinine is 250 umol/l. Urine dipstick shows
blood ++ and protein +.

Whot is the most useful investigation?

1- Intravenous urogram

2- Renal ultrasound

3- Renal biopsy

4- DTP A scan

5- MRI of kidneys

Answer & Comments

Answer: 3- Renal biopsy

Although there is a possibility of renovascular
disease, this patient has urinalysis showing
likely glomerulonephritis as a cause of renal
impairment, hence renal biopsy is the best
investigation.

[ Q: 391 ] MRCPass - Nephrology

A 55 year old man had a renal
transplant 2 years ago. He is on ciclosporin,
prednisolone and tacrolimus. He now has
several symptoms.

Which one of the following is a side effect of
ciclosporin ?

1- Hypokalaemia

2- Alopecia

3- Gum hypertrophy

4- Hemiparesis

5- Nephrotic syndrome

Answer & Comments

Answer: 3- Gum hypertrophy

Hyperkalaemia, hirsutism, tremors,
hypertension, nausea and vomiting, headache,
gum hypertrophy, parasthesiae and
hypomagnesaemia are side effects of
ciclosporin.

[ Q: 392 ] MRCPass - Nephrology

A 25 year old man has loin pains on
the left. His urine dipstick shows blood++ and
no protein. MSU culture shows no growth. An
abdominal XR shows 2 calculi in the left kidney
with a ground glass appearance.

Which of the following is the management?

1- Treatment is with urine acidification

2- D-penicillamine should be commenced

3- He should be advised to drink less water

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4- He should have the calculi removed
surgically

5- Bendrofluazide should be commenced

Answer & Comments

Answer: 2- D-penicillamine should be
commenced

The ground glass appearance of the stones
suggests cysteine stones. Cystinuria, an
autosomal recessive disease, results from
excessive excretion of the four basic amino
acids, cystine, ornithine, lysine, and arginine
(COLA) into the urine. Cystine is relatively
insoluble in acid urine.

[ Q: 394 ] MRCPass - Nephrology

A 40 year old woman has a history of
Raynaud's phenomenon, stiffness in the
hands, butterfly rash on her face and
arthralgia. She has a blood pressure of 175/90
mmHg. Urine dipstick shows protein ++ and
blood +.

Blood tests reveal a creatinine of 145 pmol/l,
ESR 60 mm/hour and positive ANA 1/160
titres.

Which of the following is most likely to be the
result of the renal biopsy?

1- Mesangial IgA staining and proliferative
glomerulonephritis

Increased fluid intake is recommended to
minimise calculi formation. D-penicillamine
decreases the urinary excretion of cystine by
binding cystine to form the more soluble
cystine - S - penicillamine complex that is 50
times more soluble than cystine.

[ Q: 393 ] MRCPass - Nephrology

A 65 year old man has a cystoscopy
to investigate haematuria. He develops
pyrexia a day after the procedure.

Which one of the following organisms is most
likely to be implicated?

1- Proteus

2- Enterococcus faecalis

3- Pseudomonas

4- Staph epidermidis

5- Staph aureus

Answer & Comments

Answer: 4- Staph epidermidis

The commonest organisms infecting causing
UTI are E coli, and following that, klebsiella,
proteus are next commonest and then
enterococci. How ever, following cystoscopy /
instrumentation, staph epidermidis (coagulase
negative staph) infection is the commonest.

2- Subendothelial deposits and focal
glomerulonephritis

3- Deposition of IgA, IgG, IgM and
complements with proliferative
glomerulonephritis

4- Spikes on silver staining with crescentic
glomerulonephritis

5- Necrotising vasculitis

Answer & Comments

Answer: 3- Deposition of IgA, IgG, IgM and
complements with proliferative

glomerulonephritis

There are various forms of lupus nephritis, but
the pathognomonic feature is with a full
house of immunostaining in the mesangium
and capillary loops with all immunoglobulins
and complements.

Mesangial IgA staining is seen in IgA
nephropathy.

Spikes on silver staining is seen in
membranous glomerulonephritis.

Necrotising vasculitic changes are seen in
small vessel vasculitis.

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[ Q: 395 ] MRCPass - Nephrology

A diabetic patient is assessed for
proteinuria in outpatients.

Which of the following urine albumin
concentrations over 24 hours signify
microalbuminuria?

1- 1 mg

2- 10 mg

3- 100 mg

4- 500 mg

5- lg

HC0 3 40 mmol/l

BE + 18 mmol/l

What is the likely diagnosis?

1- Bulimia

2- Bartter's syndrome

3- Diuretic abuse

4- Laxative abuse

5- Congenital adrenal hyperplasia

Answer & Comments

Answer: 2- Bartter's syndrome

Answer & Comments

Answer: 3-100 mg

Microalbuminuria defined as a urine albumin
excretion between 30-300 mg/day. A
concentration above 300 mg/day signifies
albuminuria. A concentration above 3g/day
signifies overt proteinuria in the nephrotic
range.

[ Q: 396 ] MRCPass - Nephrology

A 15 year old boy is being
investigated for growth retardation. He has
had no previous medical problems. He
mentions that he had symptoms of worsening
muscle weakness and fatigue. He also has
polyuria.

Investigations revealed:
urea 8 mmol/l

serum creatinine 118 pmol/l
potassium 2.8 mmol/l
sodium 133 mmol/l
chloride 79 (95-107) mmol/l
calcium 2.3(2.25-2.7) mmol/l
phosphate 0.86 (0.8-8) mmol/l
magnesium 0.9 (0.67-0.96) mmol/l
A metabolic alkalosis was present:
pH 7.58

Bartter's syndrome is hypokalaemic alkalosis
due to hyperaldosteronism.

Classical Bartter's syndrome is characterized
by early childhood onset and is due to
defective chloride transport across the
basolateral membrane in the distal nephron as
a result of mutations in the chloride channel
gene.

Symptoms may include polyuria, polydipsia,
vomiting, constipation, salt craving, and a
tendency to dehydration.

Hypokalaemia can lead to muscle weakness,
spasms, tetany, or palpitations. Urine calcium
excretion is high, leading to nephrocalcinosis,
while serum magnesium levels are normal.

[ Q: 397 ] MRCPass - Nephrology

A 50 year old man presents with a 15
year history of lithium carbonate therapy for
bipolar affective disorder. He is polyuric and
has 3 g/24 hours of proteinuria. Creatinine is
145 micromol/l.

What is a renal biopsy likely to show ?

1- ANCA positive vasculitis

2- Crescentic glomerulonephritis

3- Minimal change glomerulonephritis

4- Interstitial nephritis

5- IgA glomerulonephritis

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Answer & Comments

Answer: 4- Interstitial nephritis

With lithium toxicity, chronic interstitial
nephritis occurs. A secondary FSGS lesion due
to hyperfiltration of remnant nephrons can be
seen in 30% of cases.

[ Q: 398 ] MRCPass - Nephrology

A 75 year old woman was brought to
the hospital following a fall. Her neighbour
thinks that she was on the floor for about 4
days.

Her blood results show: sodium 132 mmol/l,
potassium 6.5 mmol/l, urea 38 pmol/l,
creatinine 650 pmol/l, calcium 1.9 (25-2.7)
mmol/l, phosphate 2.5 (0.8-1.4) mmol/l.

Which of the following investigations is most
likely to reveal the diagnosis?

1- Ultrasound of the kidneys

2- MRA of the renal arteries

3- BM stick

4- Urine dipstick and microscopy

5- DMSA scan

Answer & Comments

Answer: 4- Urine dipstick and microscopy

The most likely diagnosis is rhabdomyolysis
and acute renal failure.

The history is suggestive along with
hyperkalaemia, hypocalcaemia and
hyperphosphataemia.

Urine dipstick will be positive for blood
(myoglobinuria) but microscopy will not show
red cells. A renal biopsy may also reveal the
diagnosis. Treatment is with hydration
(normal saline) and alkalinsation of urine with
sodium bicarbonate infusion.

[ Q: 399 ] MRCPass - Nephrology

A man who is on antihypertensives
has several symptoms and his medications
require reviewing.

Which one of the following is a complication of
thiazide diuretic therapy?

1- Neutrophilia

2- Hyperkalaemia

3- Gynaecomastia

4- Hyperuricaemia

5- Peptic ulceration

Answer & Comments

Answer: 4- Hyperuricaemia

Thiazides can cause thrombocytopaenia,
hypokalaemia (blocking NaCI channels), and
hyperuricaemia. Gynaecomastia is caused by
spironolactone.

[ Q: 400 ] MRCPass - Nephrology

A 50 year old man presents with
shortness of breath and ankle oedema.

Investigations show:

urea 7 pmol/l

creatinine 88 pmol/l

albumin 18 g/L

24 hour urinary protein excretion lOg (<0.2 g)

Renal biopsy showed normal glomeruli and
renal tubule appearances with
immunofluorescence.

What is the likely diagnosis?

1- Minimal change disease

2- Focal segmental glomerulosclerosis

3- Renal vein thrombosis

4- IgA nephropathy

5- Membranous nephropathy

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Answer & Comments

Answer: 3- Renal vein thrombosis

Focal segmental glomerulosclerosis,
membranous nephropathy, minimal change
disease and IgA nephropathy would all show
histological changes.

Renal vein thrombosis can present with
nephrotic syndrome, haematuria, loin pain
and worsening renal failure.

The most common cause is in fact, nephrotic
syndrome. Other causes are renal cell cancer,
renal transplantation, Behget syndrome,
hypercoagulable states, and antiphospholipid
antibody syndrome. Treatment is with
heparin/w arfarin.

[ Q: 401 ] MRCPass - Nephrology

Which one of the following is the
commonest cause of nephrotic syndrome in
adults?

1- Minimal change glomerulonephritis

2- Post streptoccoccal glomerulonephritis

3- IgA nephropathy

4- Membrano proliferative glomerulonephritis

5- Membranous nephropathy

Answer & Comments

Answer: 5- Membranous nephropathy

transplant. Since the transplant, he has been
on the following medications:

Cyclosporine 125 mg BD

Mycophenolate 1000 mg BD

Prednisone 20 mg od

He has, over the past week, been complaining
of joint pains and upper abdominal pains. His
temperature is currently 37.5°C and charts
showed a fever for the last 3 days.

Blood results showed:

Hb 13.5 g/dl WCC 2.8 x 10 9 /L

platelets 130 x 10 9 /L sodium 137 mmol/l

potassium 4.8 mmol/l urea 10 mmol/l

creatinine 127 pmol/l ALT 88 (5-35) U/l

ALP 70 (20-120) U/l

Bilirubin 18 (1-22) pmol/l

Serology results showed:

CMV IgM antibody - positive

EBV IgG antibody - positive

HIV test - positive.

What is the likely cause of this presentation?

1- CMV infection

2- EBV infection

3- Acute graft vs host disease

4- Pneumocystic carinii

5- Immunosuppressive drugs

Membranous nephropathy is the commonest
cause of the nephrotic syndrome in adults,
whilst in children it is minimal change disease.
The renal biopsy with membranous
nephropathy shows a thickened glomerular
basement membrane and granular IgG + C3 on
immunostaining.

^ [ Q: 402 ] MRCPass - Nephrology

/ -

# A 46 year old man had a right sided

renal transplant 4 weeks ago. He has a
creatinine which was 118 umol/l on day 1 post

Answer & Comments

Answer: 1- CMV infection

The patient is at high risk of CMV infection
due to immunosuppression and HIV infection.

CMV infection post transplant can cause
damage to the transplant graft and the
presentation can be similar to graft rejection.
Most cases of symptomatic CMV infection can
be characterized by a self-limiting syndrome
of episodic fever spikes for a period of 3 to 4

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weeks, arthralgias, fatigue, anorexia,
abdominal pain and diarrhea.

Blood tests often show leukopenia (<3 x 10 9 /l),
thrombocytopenia (150 x 10 9 /l) and liver
enzyme elevation (ALT >50 U/l).

Acute transplant rejection usually occurs
within 5-10 days of the transplant.

CMV is one of the pathogens that cause the
most serious opportunistic viral infections in
HIV-positive patients and is one of the most
common causes of AIDS-related gastritis.

[ Q: 404 ] MRCPass - Nephrology

A 35 year old woman complains of
renal colic.

Which one of the following is the most
common form of renal calculi?

1- Calcium phosphate

2- Cystine

3- Calcium carbonate

4- Calcium oxalate

5- Urate

^ [ Q: 403 ] MRCPass - Nephrology

fm -

# A 40 year old man with type 1

diabetes attends a follow up appointment in

the diabetic clinic. He has a blood pressure of

145/86 mmHg. There is no evidence of

diabetic retinopathy or neuropathy. He has an

elevated albumin:creatinine ratio in his urine.

Creatinine is 90 pmol/l.

Which of the following should be done?

1- Intravenous urogram

2- Commence on an Angiotensin Receptor
Blocker

3- Better glycaemic control

4- Consider a islet cell transplant

5- Review blood pressure in 2 months

Answer & Comments

Answer: 2- Commence on an Angiotensin
Receptor Blocker

The patient has a raised albumin:creatinine
ratio in the urine. He is likely to have
microalbuminuria, which is a sign of risk to
progressive diabetic nephropathy.
Commencing an ARB to control hypertension
has been show n to be of benefit in slowing
the progression of nephropathy.

Answer & Comments

Answer: 4- Calcium oxalate

Calcium oxalate are the commonest (75%).
Others are calcium phosphate (20%), urate
(5%) and cystine (1%).

^ [ Q: 405 ] MRCPass - Nephrology

# A 25 year old man has symptoms of
lethargy. Blood results reveal a urea of 32
pmol/l and creatinine of 350 pmol

Which of the following indicates chronic
(rather than acute) renal failure?

1- Hyperkalaemia

2- heavy proteinuria

3- Urine osmolality of 300 m osmol/kg

4- Hyponatraemia

5- Anaemia

Answer & Comments

Answer: 5- Anaemia

Anaemia (inadequate erythropoietin), renal
osteodystrophy, small scarred kidneys suggest
chronic rather than acute renal failure.

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[ Q: 406 ] MRCPass - Nephrology

A 50 year old woman who is
morbidly obese presents with a plasma
creatinine of 250 micromoles/l.

Which form of disease is likely?

1- Renal tubular acidosis

2- Focal segmental glomerulosclerosis

3- Nephritic syndrome

4- Membranous glomerulonephritis

5- Cholesterol emboli

Answer & Comments

Answer: 2- Focal segmental glomerulosclerosis

There is an association between severe
obesity and focal segmental
glomerulosclerosis.

[ Q: 407 ] MRCPass - Nephrology

A 45 year old patient is admitted
with decreased conscious level. She is oliguric
and hyperventilating. Her investigations show
: sodium 125, potassium 6.0, chloride 92 (95-
107), Urea 15 mmol/I, creatinine 220
micromol/L, arterial blood gas pH 7.2,
bicarbonate 16 mmol/I.

What is the anion gap?

1- 14

2- 16

3- 18

4- 23

5- 25

Answer & Comments

Answer: 4- 23

The anion gap is calculated with the formula
(Na+K)-(CI+HC03). In this case it is 125 + 6-92
-16 = 23.

This example indicates high anion gap,
possibly due to lactic acidosis or an overdose
of a substance.

[ Q: 408 ] MRCPass - Nephrology

A 50 year old man with a history of
hypertension was investigated for renal
impairment. Renal angiography confirms renal
artery stenosis.

Which one of the following features is an
indication for stenting in renal artery stenosis?

1- Flash pulmonary oedema

2- Abdominal bruit

3- Heavy proteinuria

4- Unilateral small kidney

5- Hypotension

Answer & Comments

Answer: 1- Flash pulmonary oedema

Revascularization is considered when the
presence of hemodynamically significant renal
artery stenosis is judged to be contributing to
poorly controlled hypertension or progressive
renal impairment. Other less common but
equally important clinical indications for RAS
revascularization include episodic pulmonary
edema, congestive cardiac failure, and
unstable angina.

[ Q: 409 ] MRCPass - Nephrology

A 20 year old male has taken a drug
overdose of multiple drugs.

Which one of the following can be effectively
removed by haemodialysis?

1- Amiodarone

2- Digoxin

3- Phenytoin

4- Lithium

5- Paraquat

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Answer & Comments

Answer: 4- Lithium

Answer & Comments

Answer: 1- Renal amyloidosis

Drugs with a large volume of distribution are
poorly dialysed. Haemodialysis is effective in
lithium poisoning.

[ Q: 410 ] MRCPass - Nephrology
A 25 year male diagnosed type I

diabetes.

Whot ore his chances of progressing tow ords
End Stage Renal Disease (ESRD)?

1 - 10 %

2- 25%

3- 50%

4- 75%

5- 100%

Answer & Comments

Answer: 3- 50%

In type I diabetes, there is a 50% chance of
progressing tow ards ESRD. In type II diabetics,
there is a 15% chance of doing so.

Renal vein thrombosis is most commonly
associated with nephrotic syndrome, the
commonest due to membranous
glomerulonephritis. Other causes are
nephrotic syndrome due to amyloidosis,
vasculitis, dehydration and congestive cardiac
failure. Treatment is with anticoagulation, and
when response is poor, thrombolysis and
thrombectomy can be considered.

[ Q: 412 ] MRCPass - Nephrology

An 8 year old boy has bowing of the
weight-bearing long bones.

Which one of the following is a feature of X-
linked hypophosphataemic vitamin D -
resistant rickets?

1- High serum phosphate

2- High urinary phosphate

3- High parathyroid hormone (PTH) levels

4- Hypercalcaemia

5- Low bicarbonate

^ [ Q: 411 ] MRCPass - Nephrology

if -

# A 55 year old man has a creatinine of
280 pmol/l. He mentions a 10 day history of
loin pain and pink coloured urine. An
ultrasound of the kidney suggests renal vein
thrombosis.

Which of the following conditions is most likely
to be associated?

1- Renal amyloidosis

2- Interstitial nephritis

3- Systemic sclerosis

4- Renal calculus

5- Reflux nephropathy

Answer & Comments

Answer: 2- High urinary phosphate

In X-linked hypophosphataemic Vit D resistant
rickets, serum phosphate is low and urine
phosphate is high due to inappropriate renal
phosphate wasting. Serum parathyroid levels
are usually normal or slightly elevated.
Clinically, the most obvious of these aspects is
the effect on bone formation and growth that
causes very severe rickets, especially in
affected males. Treatment is with oral
phosphate (difficult to tolerate) and high dose
activated Vitamin D.

[ Q: 413 ] MRCPass - Nephrology
A 55 year old woman has end stage

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renal failure and is being considered for
dialysis.

In which one of the following situations, might
peritoneal dialysis be preferable to
hemodialysis?

1- In hypercatabolic patients

2- Recent abdominal wound

3- In patients bordering on respiratory failure

4- In diabetic patients

5- When there is a need to conserve plasma
protein levels

Answer & Comments

Answer: 4- In diabetic patients

Peritoneal dialysis can be useful for
intraperitoneal insulin administration.

Hemodialysis is preferable in hypercatabolic
patients for rapid urea clearance. Stress is
placed on the abdominal w ound healing by
PD, and on the diaphragm in respiratory
failure. There is a loss of protein by diffusion
in PD, hence less useful when protein needs to
be conserved.

[ Q: 414 ] MRCPass - Nephrology

* A 42 year old man is referred to the
renal physician due to symptoms of
haemoptysis and haematuria. These
symptoms have been going on for 6 months.
Investigations show:

sodium 135 mmol/l

potassium 4.6 mmol/l

urea 18 mmol/l

creatinine 260 pmol/l

The likely disease is caused by an antibody
against which of the following?

1- Smooth muscle

2- DsDNA

3- Proteinase 3

4- Macrophages

5- Microfilaments

Answer & Comments

Answer: 3- Proteinase 3

The diagnosis would fit Wegener's
granulomatosis, which is commonly cANCA
positive. In patients with vasculitis,
approximately 90 percent of cytoplasmic
ANCA are PR3-ANCA and approximately 90
percent of perinuclear ANCA are MPO-ANCA.

[ Q: 415 ] MRCPass - Nephrology

A 45 year old woman presents with
dipstick positive haematuria. Her blood tests
reveal a urea of 25 pmol/l and creatinine of
260 pmol/l.

Which of the following most strongly suggests
post streptococcal glomerulonephritis?

1- History of previous attacks

2- Papilloedema

3- Sore throat 10 days ago

4- Complete anuria

5- Nephrotic syndrome

Answer & Comments

Answer: 3- Sore throat 10 days ago

Post streptococcal glomerulonephritis is
caused by Group A beta haemolytic
streptococci. A second episode is unusual in
those who have previously had the disease
because there is good immunity to the cell
wall proteins of Group A strep. Although
features of hypertension with papilloedema,
complete anuria and nephrotic syndrome can
occur, the strongest predictor is the clinical
history of sore throat suggesting infection
with streptococci leading to nephritic
syndrome.

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This glomerulus is hypercellular and capillary
loops are poorly defined in post streptococcal

glomerulonephritis.

[ Q: 416 ] MRCPass - Nephrology

A 20 year old patient complains of
ankle sw elling and breathlessness. Her CXR
shows pleural effusions.

Blood tests show :

urea 7 pmol/l

creatinine 80 pmol/l

sodium 138 mmo

potassium 4.2 mmol/l
alanine transferase 20 U/L
bilirubin 16 umol/L
albumin 20 g/L (34-94)
total cholesterol 8.8 mmo

Whot is the next best investigation?

1- Ultrasound of liver

Proteinuria

Hypoalbuminemia

Oedema

This is frequently accompanied by
Hypercholesterolemia

[ Q: 417 ] MRCPass - Nephrology

A 45 year old man with no previous
past medical history presents with a BP of
180/100 mm Hg, frothy urine and peripheral
oedema. There is + blood and +++ protein on
urinalysis. 24-hour protein loss is 5 grams.

Plasma albumin is 25 g/L. Plasma C3 is 0.10
(low ). Plasma creatinine is 160 umol/l. A renal
biopsy is performed.

Which of the following is most likely to be
found on the biopsy?

1- Minimal change glomerulonephritis

2- Mesangiocapillary glomerulonephritis

3- IgA nephropathy

4- Post streptococcal glomerulonephritis

5- Focal segmental glomerulosclerosis

Answer & Comments

Answer: 2- Mesangiocapillary

glomerulonephritis

2- Antinuclear antibody

3- Urinary protein estimation

4- Renal biopsy

5- 24 hour urine creatinine clearance

Answer & Comments

Answer: 3- Urinary protein estimation

The high cholesterol and low albumin suggests
nephrotic syndrome (>3g protein excretion in
24 hour urine collection).

The triad of features of nephrotic syndrome
are:

This man has nephrotic syndrome

(hypoalbuminaemia, oedema, and
proteinuria). MCGN presenting in a young
man with nephrotic syndrome and

hypertension and hypocomplementaemia
would fit best. Post streptococcal

glomerulonephritis is possible but the
infection should be clinically apparent, or in
the history.

The two most common variants of MCGN are
type I MCGN and type II MCGN (also called
dense deposit disease).

Type I is much more common than type II,
which is a rare disease. They are characterized

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by capillary basement membrane thickening
and mesangial cell proliferation. They are
associated with low levels of C3.
Mesangiocapillary glomerulonephritis is a
significant cause of nephrotic syndrome in
children (accounts for about 8% of cases) and
adults (accounts for about 14%).

The figure shows MCGN with coarse granular
depostition of IgA, IgM and C3.

[ Q: 418 ] MRCPass - Nephrology

A 60 year old lady has been noted
for the first time to have renal impairment.

Which of the following features is most useful
in determining whether the renal failure is
acute or chronic?

1- Renal size of 7.5 and 8 cm

2- Hbof 12 g/dl

3- Blood pressure of 160/90

4- PTH level of 8 pmol/l

5- Phosphate of 2 mmol/l

Answer & Comments

Answer: 1- Renal size of 7.5 and 8 cm

Out of all the options small renal size is the
best feature suggesting chronic renal failure.

[ Q: 419 ] MRCPass - Nephrology

A 15 year girl presents with a
nonblanching rash over his shins and a sw
ollen knee. He has noticed haematuria.

Blood test show a urea of 12 pmol/l and
creatinine 220 pmol/l. Urine dipstick show s:
blood +++, protein +.

What is the renal biopsy likely to show ?

1- Tubular necrosis

2- Podocyte fusion

3- Mesangial deposits of IgA

4- Thickening of basement membranes

5- Focal segmental sclerosis

Answer & Comments

Answer: 3- Mesangial deposits of IgA

The clinical presentation fits Henoch Schonlein
purpura. This is an autoimmune disorder
(cause unknow n but associated with
mycoplasma), which is related to
multisystemic IgA deposition. It is usually a
self-limited disease. It is the most common
form of childhood vasculitis and results in
inflammatory changes in small vessels.

The symptoms of Henoch-Schonlein Purpura
usually begin suddenly and may include
headache, fever, loss of appetite, cramping
abdominal pain, and joint pain. Red or purple
spots typically appear on the skin (petechial
purpura). Inflammatory changes associated
with Henoch-Schonlein Purpura can also
develop in the joints, kidneys, digestive
system, and, in rare cases, the brain and spinal
cord. Mesangial Ig A deposits are typical
features of HSP on the renal biopsy.

/ i

1 _ m

Henoch Schonlein Purpura

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^ [ Q: 420 ] MRCPass - Nephrology

fi -

# A 50 year old lady has been
diagnosed with type 2 diabetes, a year ago.
Since the diagnosis was made, she was found
to have pre-proliferative diabetic retinopathy.
She has a history of rheumatoid arthritis and
has been taking ibuprofen regularly for 6
years. She was referred for investigation of
renal impairment.

The HbAlC is 9

urea 15 mmol/l

creatinine 200 pmol/l

Urine dipstick shows blood +, protein ++

What is the likely diagnosis?

1- Diabetic nephropathy

2- Amyloidosis

3- Chronic interstitial nephritis

4- Renal calculi

5- Acute analgesic nephropathy

Answer & Comments

Answer: 1- Diabetic nephropathy

Diabetic nephropathy, amyloidosis and
chronic interstitial nephritis are all possible
answers. The rationale is that the patient has
had poorly controlled diabetes for a while in
view of the high HbAlC and retinopathy, and
has developed nephropathy.

Diabetic Nephropathy progresses over 10 to
25 years. Hyperfiltration without
microalbuminuria appears initially and
advances to a GFR 20 to 50% above normal
and microalbuminuria > 300 mg/24 h. GFR
normalizes with early renal injury and mild
hypertension and progresses to frank
hypertension, with proteinuria > 0.5 g/day.
Heavy proteinuria and a progressive decline in
renal function precedes end-stage renal
disease.

[ Q: 421 ] MRCPass - Nephrology

A 30 year old man had progressive
deafness and hematuria from childhood and
had undergone renal transplant eight years
ago for chronic renal failure. Examination
revealed perceptive high-tone deafness and
posterior lenticonus in both eyes.

What is the likely diagnosis?

1- Neurofibromatosis type II

2- Romano Ward syndrome

3- Alport's syndrome

4- Adult polycystic kidney disease

5- Wegener's granulomatosis

Answer & Comments

Answer: 3- Alport's syndrome

Classic Alport's syndrome is an X linked
disorder characterised by a triad of
progressive hematuric nephritis, progressive
perceptive high-tone hearing loss, and ocular
signs (cataracts, spherophakia, and posterior
lenticonus).

[ Q: 422 ] MRCPass - Nephrology

A 14 year old boy presents with
generalised oedema. There was no relevant
past medical history.

Investigations revealed: Creatinine 75 pmol/l,
Albumin 20 g/l, 24 hour urine protein
excretion 3.2 g. Ultrasound scan shows normal
renal size.

Which of the following should the patient be
treated with initially?

1- Cyclophosphamide

2- Peritoneal dialysis

3- Thiazides

4- Haemodialysis

5- Prednisolone

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Answer & Comments

Answer: 5- Prednisolone

The diagnosis is minimal change
glomerulonephritis presenting with nephrotic
syndrome. 80% of patients achieve remission
with prednisolone therapy. Cyclophosphamide
treatment can be started for those who are
steroid resistant.

[ Q: 423 ] MRCPass - Nephrology

A 16 year old girl has presented with
joint pains, abdominal pains and has a rash on
her lower limbs.

patients with renal involvement, as many as
10% may develop chronic renal failure and
end-stage renal disease. Biopsy of affected
renal tissue shows a spectrum of glomerular
disease from minimal change to severe
crescentic glomerulonephritis. IgA, C3, fibrin,
properdin are seen as granular mesangial
deposits on direct immunofluorescence.

[ Q: 424 ] MRCPass - Nephrology

A 25 year old woman has recurrent
UTIs during childhood. She is now 28 weeks
pregnant and has another episode of
pyelonephritis. Her renal function is normal.

Investigations show:

Urea 14 mmol/I

Creatinine 180 umol/l

Urine dipstick: blood ++, protein +

A renal biopsy was performed and results
showed - IgA linear deposited in basement
membrane.

What is the likely predisposing problem?

1- Toxic shock syndrome

2- Renal calculi

3- Reflux nephropathy

4- Pre eclampsia

5- Polycystic kidneys

Whot is the diagnosis?

1- Haemolytic uraemic syndrome

2- Goodpasture's syndrome

3- Wegener's granulomatosis

4- Henoch Schonlein purpura

5- IgA nephropathy

Answer & Comments

Answer: 4- Henoch Schonlein purpura

In Henoch Schonlein purpura, a purpuric rash
typically appear on the lower extremities and
buttocks, but may also involve the upper
extremities, face and trunk, and are
accentuated in areas of pressure. HSP
nephritis usually presents as macroscopic
hematuria and proteinuria lasting days to
weeks.

These may be accompanied by increased
plasma creatinine and/or hypertension,
followed by microscopic hematuria. Of those

Answer & Comments

Answer: 3- Reflux nephropathy

Pyelonephritis is not a common presentation
in pregnancy and should be treated
aggressively with antibiotics. In a patient with
recurrent childhood UTIs, reflux nephropathy
predisposes to pyelonephritis due to renal
scarring.

[ Q: 425 ] MRCPass - Nephrology

A 25 year old woman is in the third
semester of pregnancy. She has several
investigations for proteinuria.

Which one of the following results is
significant?

1- GFR 140 ml/min

2- Urea 2 mmo

3- Uric acid 1.5 mmol/I

4- Creatinine 60 pmol/l

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5- Sodium 135 mmol/l

IgA nephropathy

Answer & Comments

Answer: 3- Uric acid 1.5 mmol/l

Normal uric acid level is < 0.4 mmol/l. A high
uric acid level may indicate pre-eclampsia.

Henoch-Schonlein purpura
systemic lupus erythematosus
mixed cryoglobulinemia
Goodpasture's syndrome

[ Q: 426 ] MRCPass - Nephrology

A 73 year old man presented with a
two day history of a pruritic rash and oedema
affecting both lower legs.

Examination showed non-palpable, non¬
tender purpura affecting both legs, with
pitting oedema, and urticarial lesions on the
left knee and anterior chest. Testing of urine
was positive for protein and blood. Urine
microscopy showed > 100 erythrocytes per

10 6 /l.

What is the clinical scenario consistent with?

1- Renal tubular acidosis

2- Nephrotic syndrome

3- Nephritic syndrome

4- Renal artery stenosis

5- Renal cell carcinoma

Answer & Comments

Answer: 3- Nephritic syndrome

Acute nephritic syndrome most often results
from infection by streptococcus.

Infectious causes of acute nephritic syndrome
are:

Wegener's granulomatosis

[ Q: 427 ] MRCPass - Nephrology

A 45 year old man feels unwell
following a sore throat and cough. He has a
blood pressure of 170/90 mHg.

Dipstick of his urine reveals blood ++ and
protein ++. His blood tests show:

Hb 10.5 g/dl, MCV 85 fl, WCC 7 x 10 9 /L,
platelets 200 x 10 9 /L, sodium 135 mmol/l,
potassium 4.2 mmol/l, urea 15 pmol/l,
creatinine 260 pmol/l, ALT 25 (5-35) U/l, AST
35 (1-35) U/l, ALP 75 (20-120) U/l, GGT 30 (4-
35) U/l, Bilirubin 18 (1-22) pmol/l, Albumin 38
(37-49) g/l, calcium 2.1 (2.25-2.7) mmol/l,
phosphate 7.5 (0.8-8) pmol/l. C3 - 0.5 g/L (0.8
- 1.6), C4 - 0.17 g/L (0.15 - 0.55). C3 nephritic
factor is positive.

Ultrasound scan of his kidneys reveal a 8.5 cm
length kidney on the left and 9.3 cm on the
right.

What is the diagnosis?

1- Post streptococcal glomerulonephritis

2- Acute tubular necrosis

3- Membrano-proliferative glomerulonephritis

4- mesangiocapillary glomerulonephritis

staphylococcus

5- Adult polycystic kidney disease

pneumococcus

chickenpox

malaria

Non infectious causes:
Membranoproliferative glomerulonephritis

Answer & Comments

Answer: 4- mesangiocapillary

glomerulonephritis

The patient has chronic renal failure likely
secondary to mesangiocapillary

glomerulonephritis.

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Membranoproliferative glomerulonephritis
(MPGN) can present with the nephrotic
syndrome, nephritic syndrome, or, most
often, a mixture of the two.

The two most common variants of MPGN are
type I MPGN (also called mesangiocapillary
glomerulonephritis) and type II MPGN (also
called dense deposit disease). Type I is much
more common than type II. Patients with
MPGN often have hypocomplementemia and
a circulating autoantibody called C3 nephritic
factor, which binds to the C3 convertase of
the alternative pathw ay. It causes inactivation
of C3 in the alternate pathway by cleaving C3
into two inactive fragments, C3c and C3d,
instead of the normal C3b.

Although the clinical scenario may fit post
streptococcal glomerulonephritis,

Mesangiocapillary GN is more likely because
C3 nephritic factor is not usually associated
with acute poststreptococcal

glomerulonephritis.

[ Q: 428 ] MRCPass - Nephrology

An 18 year old male has had a 5 year
history of renal failure.

On examination, he had hilar adenopathy, but
maculopapular rashes, erythema nodosum,
arthritis, chronic lymphocytopenia,
hepatomegaly, splenomegaly.

A renal biopsy specimen revealed
tubulointerstitial nephritis and non caseating
granulomatous lesions.

What is the diagnosis?

1- Wegener's granulomatosis

Sarcoidosis is a chronic, multi-system
granulomatous disorder of unknown etiology
characterized by non-caseating granulomas.
The most commonly affected organ is the
lung, other organs include the lymph nodes,
skin, eyes, parotid glands, bones, joints, liver
and kidney. Patients mostly present with
respiratory symptoms, or joint and skin
manifestations.

Renal involvement and presentation with
renal failure are relatively rare in sarcoidosis.
Renal sacroidosis is reported to have three
categories: 1) renal changes by abnormal
calcium metabolism, 2) interstitial nephritis or
granulomatous nephritis or granulomatous
nephritis and 3) glomerulonephritis (mostly
membranous).

[ Q: 429 ] MRCPass - Nephrology

A 35 year man has been referred for
management of hypertension. On
examination he had palpable kidneys. This
was confirmed by abdominal ultrasound
which showed multiple cysts.

Which of the following is likely to be
associated?

1- Polycythaemia

2- Nail pitting

3- Hypermobility

4- Mitral stenosis

5- Hypogonadism

Answer & Comments

Answer: 1- Polycythaemia

2- Lupus nephritis

3- Renal tuberculosis

4- Sarcoidosis

5- Renal calculi

Answer & Comments

Answer: 4- Sarcoidosis

Polycystic kidney disease is associated with
increased levels of EPO which lead to
polycythaemia. Aneurysms of cerebral arteries
(berry aneurysms) have been reported in 10-
50% of patients. A variety of cardiac and aortic
abnormalities have been associated with
APKD, including aortic root dilatation, aortic
regurgitation, bicuspid aortic valves,

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coarctation of the aorta, mitral regurgitation
and abdominal aortic aneurysm.

^ [ Q: 430 ] MRCPass - Nephrology

n -

# A 30 year old lady has haematuria on
the dipstick and was referred by the GP for
further investigation. She eventually has a
renal biopsy which shows mesangial
hypercellularity with IgA deposition.

What is the diagnosis?

1- Mesangiocapillary glomerulonephritis

2- IgA nephropathy

3- HIV nephropathy

4- Nephrotic syndrome

5- Interstitial nephritis

Answer & Comments

Answer: 2- IgA nephropathy

The diagnosis is IgA nephropathy. IgA
nephropathy is the commonest
glomerulonephritis but only 30% progress
towards end stage renal failure. It rarely
causes nephrotic syndrome, and more
commonly presents with microscopic
haematuria. HIV is associated with a focal
segmental and immune complex
glomerulonephritis.

[ Q: 431 ] MRCPass - Nephrology

A 27 year old lady who is 20 weeks
pregnant is found to have 2+ proteinuria on
dipstick. Her blood pressure is 155/80 mmHg.
Creatinine is 100 pmol/l. A 24 hour urinary
protein excretion was measured at 1.6 g. She
is commenced on labetalol and her blood
pressure is controlled. Ultrasound of the
kidneys show normal size.

Following the pregnancy she has an
intravenous urogram which shows scarring in
the upper pole of the left kidney.

What is the likely diagnosis?

1- Reflux nephropathy

2- Minimal change glomerulonephritis

3- IgA nephropathy

4- Hypertensive nephropathy

5- Membranous nephropathy

Answer & Comments

Answer: 1- Reflux nephropathy

Reflux nephropathy can lead to proteinuria,
renal impairment and hypertension.
Pregnancy can precipitate the symptoms.

The pathology may be due to reflux of
infected urine, incompetent vesico-ureteric
valves or abnormal renal papillae which result
in intra-renal reflux. Grades I and II reflux are
managed conservatively, with improved
hygiene, high fluid intake and regular voiding.
Grades III and IV reflux require surgical
management - ie correction of the underlying
abnormality. This is by tunneling the ureter
through the bladder wall.

[ Q: 432 ] MRCPass - Nephrology

A 30 year old man has returned from
a trip to India recently. He presents with
bloody diarrhoea which started three weeks
ago. He now has malaise and sw elling of his
legs. He has poor urine output. Blood tests
show:

Hb 8 g/dL

White cell count 14 x 10 9 /L
Neutrophils 9 x 10 9 /L
Platelets 20 x 10 9 /L
PT 13s, APTT 33s
Fibrinogen 4 g/dL
sodium 136 mmol/L
potassium 6.1 mmol/L
urea 30 mmol/L
creatinine 440 umol/L

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albumin 30 g/L.

Urine dipstick: blood ++, protein +.

Whot is the next best investigation to confirm
the likely diagnosis?

1- Renal biopsy

2- Stool culture

3- MRA of kidneys

4- Ultrasound of kidneys

5- 24 hour urine collection for creatinine
clearance

Answer & Comments

Answer: 2- Stool culture

The diagnosis is haemolytic uraemic syndrome
(HUS). The typical presentation is with a triad
of acute renal failure, Microangiopathic
haemolytic anaemia and thrombocytopaenia.
Most commonly the cause is E coli 0157
(verotoxin producing E coli), hence stool
cultures would be the best investigation to
confirm the diagnosis in this case. Other
causes are shigella, ciclosporin and connective
tissue diseases. The thrombocytopenia is
thought to be a consequence of platelet
consumption at sites of endothelial injury.
Despite this blood clotting times (prothrombin
time, kaolin clotting time) are normal.

Answer & Comments

Answer: 5- Reflux nephropathy

The term chronic pyelonephritis due to reflux
nephropathy is reserved for a condition
resulting from long-standing vesicoureteral
reflux and infection leading to chronic
interstitial nephritis and parenchymal scarring.
This condition usually begins in childhood and
occurs more frequently in females.

^ [ Q: 434 ] MRCPass - Nephrology

* A 44 year old renal transplant
recipient has been on prednisolone and
azathioprine for several months. He has
suddenly developed a cough and fevers. On
investigation, he was found to have a Hb of 9
g/dl and a WCC of 3 x 10 9 /L.

What is the most likely cause?

1- Pneumonia

2- Prednisolone

3- Low EPO

4- Folate deficiency

5- Azathioprine

Answer & Comments

Answer: 5- Azathioprine

[ Q: 433 ] MRCPass - Nephrology

A 30-year-old female with chronic
urinary tract infections presents for
investigations. Ultrasound scan reveals
scarring over the renal calyces.

Which one of the following is most likely?

1- Analgesic nephropathy

2- Polycystic kidney disease

3- Nephrotic syndrome

4- Post streptoccocal glomerulonephritis

5- Reflux nephropathy

Immunosuppressives used in renal transplant
can often cause a pancytopenia. In this case,
azathioprine, which is well known to cause
bone marrow suppression had led to the
predisposition towards infection.

[ Q: 435 ] MRCPass - Nephrology

A 12 year old male was admitted to
the emergency department with significant
lethargy which had worsened over the past
year.

On examination he was conscious and
orientated. His heart rate was 70 beats per
minute, blood pressure was 120/70mmHg and

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he was afebrile. Clinical examination of the
abdomen revealed minimal no organomegaly.

His haemoglobin is 11.2 g/dL, white cell count
of 8.2 x 10 9 /L and a platelet count of 365 x
10 9 /l_. The plasma urea was 11.1 mmol/L,
creatinine 117 umol/L, sodium 132 mmol/L ,
potassium 2.3 mmol/L, bicarbonate 8 mmol/L.

The plasma liver function tests were within
normal limits. His electrocardiogram
demonstrated U waves.

Which one of the following is the likely
diagnosis?

1- ACE inhibitor therapy

2- Liddle's syndrome

3- Pituitary tumour

4- Renal artery stenosis

5- Ciclosporin treatment

Answer & Comments

Answer: 2- Liddle's syndrome

3-w eek history of malaise, fever and
shivering. Urine dipstick showed microscopic
haematuria.

Over the next week, his blood urea rose
steadily from 10 to 23mmol/l (NR 2.5-7.5) and
the serum creatinine from 164 to 515pmol/l
(NR 60-120). His haemoglobin was 9g/l,w hite
cell count of 10.4 x 10 9 /L.

His urine contained red cell casts and he
rapidly became oliguric. Antinuclear
antibodies, including anti-DNA antibodies,
were not detected and serum C3 and C4 levels
were normal.

A renal biopsy specimen contained seven
glomeruli: four showed focal necrotizing
glomerulonephritis with epithelial crescents
but the remaining three were normal. On
immunofluorescence, linear staining with IgG
was present along the glomerular capillary
basement membrane.

What is the diagnosis?

1- Lupus nephritis

Liddle's syndrome is caused by a mutation in
the sodium channel (ENaC) in the distal
nephron.

There is increased sodium reabsorption and
potassium loss. Hence the condition is
characterised by hypokalaemic alkalosis,
hypertension, and negligible aldosterone
secretion. Treatment is with triamterene. The
condition is also sometimes called

pseudohyperaldosteronism.

Hypokalemia with a metabolic alkalosis may
be due to vomiting, excess nasogastric fluid
loss, hyperaldosteronism, Bartter's syndrome,
Gitelman's variant, Liddle's syndrome

(pseudoaldosteronism), Cushings syndrome,

ectopic corticotropin producing tumours,

VIPoma, mineralocorticoid excess, excess
liquorice intake and diuretics.

[ Q: 436 ] MRCPass - Nephrology
A 45 year old man presented with a

2- Interstitial nephritis

3- Wegener's granulomatosis

4- Anti GBM disease

5- IgA nephropathy

Answer & Comments

Answer: 4- Anti GBM disease

Antiglomerular basement membrane (anti-
GBM) antibody disease is a rare autoimmune
disorder in which circulating antibodies are
directed against an antigen normally present
in the GBM and alveolar basement
membrane.

Presentation is with haemoptysis, haematuria,
fever, malaise, weight loss, and fatigue.

At immunofluorescent microscopy of renal
biopsy specimens, the linear deposition of IgG
along the glomerular capillaries and,
occasionally, the tubules is nearly
pathognomonic.

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Immunofluorescence staining for IgG reveals
diffuse high-intensity linear staining of the
glomerular basement membrane in a patient
with anti-GBM disease.

[ Q: 437 ] MRCPass - Nephrology

A 20 year old man had type 1
diabetes or 5 years. He now presents with leg
oedema. On Investigations, he was found to
have a urinary protein of 5 g/24 hours and
serum cholesterol 8 mmol/l.

Whot is the most likely diagnosis.

1- Diabetic nephropathy

2- IgA nephropathy

3- Post streptococcal glomerulonephritis

4- SLE

5- Minimal change disease

Answer & Comments

Answer:

5- Dialysis dependent renal failure never
occurs

Answer & Comments

Answer: 4- Renal vein thrombosis

Selective proteinuria is more of a feature in
minimal change glomerulonephritis.

Membranous glomerulonephritis accounts for
1/3 of patients with nephritic syndrome. The
renal biopsy shows IgG and C3 subepithelial
deposition on the basement membrane.
Streptococcal infection suggests nephritic
syndrome, which would present with
haematuria predominantly. End stage renal
failure occurs in 1/3 of patients and if so,
immunosuppresants such as

cyclophosphamide, steroids and chlorambucil
are recommended. Renal vein thrombosis
occurs in about 10% of patients with nephrotic
syndrome and membranous

glomerulonephritis.

[ Q: 439 ] MRCPass - Nephrology

A 20 year old man presented with an
18-month history of intermittent, painless
haematuria, usually occurring after strenuous
exercise, but without dysuria or increased
frequency of micturition. He also had frequent
colds and sore throats and believed that the
haematuria increased at these times.

[ Q: 438 ] MRCPass - Nephrology

A 40 year old man has proteinuria
with a dipstick demonstrating +++ of protein.
He has a history of diabetes, and a albumin of
26 g/l. A physician suspects membranous
glomerulonephritis.

Which of the following is likely to support this
diagnosis?

1- Selective proteinuria

2- IgM deposits around the renal tubules

3- Recent streptococcal throat infection

4- Renal vein thrombosis

On examination, he appeared fit and healthy;
his blood pressure was 150/75. Urine analysis
showed microscopic haematuria (3+) and a
trace of protein. Intravenous urography, a
micturating cystogram and cystoscopy were
normal. His haemoglobin, white-cell count,
blood urea and creatinine clearance were
normal; the urinary protein excretion was
0.95g/day. Immunoglobulin, CH50, C4 and C3
levels were within normal limits.

In view of the duration of haematuria, a renal
biopsy was performed. The glomeruli showed
a diffuse increase in mesangial cells with
thickening of the matrix. Immunofluorescent

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examination of the biopsy showed mesangial
deposits of IgA and C3.

What treatment should be commenced?

1- Frusemide

2- Ramipril

3- Ciclosporin

4- Tacrolimus

5- Amoxycillin

Answer & Comments

Answer: 2- Ramipril

IgA nephropathy (Berger's disease) is the most
common glomerulonephritis worldw ide.
There are mesangial IgA deposits in the
kidney. Presentation may be with a rash, frank
haematuria after an episode of pharyngitis,
arthritis or symptoms of acute renal failure.

Although it is a benign disease in most
patients, chronic renal failure and ESRD occur
in about 20-40% of patients.

Investigations reveal: urea 7 mol/I, creatinine
90 umol/L, anti dsDNA antibodies - strongly
positive, 24 hour urinary protein excretion 2.5

A renal biopsy shows membranous
nephropathy.

What is the most suitable treatment?

1- Azathioprine

2- Lisinopril

3- Calcium phosphate

4- Ibuprofen

5- Insulin

Answer & Comments

Answer: 2- Lisinopril

In lupus nephritis with membranous
nephropathy, ACE inhibitors and steroids
(prednisolone) have been show n to slow the
progression tow ards worsening nephrotic
syndrome.

Currently, no cure exists for IgA nephropathy,
but therapies that can delay the onset of need
for dialysis and transplantation are available.
ACE inhibitors are the preferred agents for low
ering blood pressure.

Light microscopy of a glomerulus from a
patient with immunoglobulin A nephropathy
showing increased mesangial matrix and

cellularity

[ Q: 441 ] MRCPass - Nephrology

A 15 year old female presents with a
short history of sudden onset of severely
swollen ankles. She is otherwise well, and
urinalysis shows +++ protein. A urine
collection shows that she is excreting 5g
protein per 24 hours, the plasma albumin is 23
g/l, creatinine 90.

What is the most likely underlying diagnosis?

1- Minimal change nephrotic syndrome

2- Focal Segmental glomerulosclerosis

3- IgA nephropathy

4- Membranous nephropathy

5- Mesangiocapillary glomerulonephritis

[ Q: 440 ] MRCPass - Nephrology

A 25 year lady has a butterfly rash
and arthralgia. Her blood pressure is 170/95.

Answer & Comments

Answer: 1- Minimal change nephrotic
syndrome

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The patient has nephrotic syndrome and at
this age the commonest underlying diagnosis
on renal biopsy is minimal change nephrotic
syndrome. This would also be consistent with
the lack of haematuria, the sudden onset and
the normal excretory renal function.

Minimal change nephropathy is responsible
for 90% of the cases of nephrotic syndrome in
children less than 5 years of age. It also occurs
in adults - approx 20%. The name is derived
from the fact that the only detectable
abnormality histologically is fusion and
deformity of the foot processes under the
electron microscope. Minimal Change Disease
is steroid-responsive and in general, does not
lead to chronic renal failure.

[ Q: 442 ] MRCPass - Nephrology

A 57 year old man with diabetic
nephropathy has a plasma creatinine of
380pmol/l.

He has the following blood results : potassium
5.2 mmol/l, calcium 2.20 mmol/I, albumin 42
g/l, phosphate 1.55 mmol/l, and PTH 1.6
pmol/l (NR 1.1-6.8).

Which of the following should be commenced?

1- Alucaps

2- Thyroxine

3- Vitamin A

4- Alfacalcidol

5- Calcium acetate

Answer & Comments

Answer: 5- Calcium acetate

Alfacalcidol could be considered for
prophylaxis against renal bone disease and
progressive hyperparathyroidism. How ever,
the patient's phosphate level is already
elevated, and vitamin D supplementation may
increase this further.

Aluminium-containing phosphate binders
(alucaps) carry the risk of aluminium
accumulation and CNS effects.

Calcium acetate or calcium carbonate can be
used. It should be taken with (or just before)
meals and may offer advantages over calcium
carbonate.

[ Q: 443 ] MRCPass - Nephrology

A 35 year old man has been given
some painkillers by his GP for pleuritic chest
pains following a chest infection.

2 weeks later he presents again with ankle
oedema.

His blood pressure is 130/70 mmHg, and urine
dipstick reveals protein +++ and no blood.
Plasma creatinine is 145 pmol/l.

What is the likely diagnosis?

1- Renal amyloidosis

2- Membranous nephropathy

3- Interstitial nephritis

4- Focal segmental glomerulosclerosis

5- Minimal change nephropathy

Answer & Comments

Answer: 3- Interstitial nephritis

The most frequent causes of acute interstitial
nephritis can be found in one of three general
categories:

drug-induced (NSAID, anti TB drugs,
sulphonamides), infection-associated

(legionella, HIV, Hep C) cases associated with
immune or neoplastic disorders (SLE, Sjogrens,
Wegeners).

The clinical presentation can range from
asymptomatic elevation in creatinine or blood
urea or abnormal urinary sediment, to
generalized hypersensitivity syndrome with
fever, rash, eosinophilia, and oliguric renal
failure.

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Proteinuria is much more common in NSAID-
induced nephritis than other causes.
Resolution of proteinuria should occur with
discontinuation of NSAID drugs, although
steroids can be used in cases of heavy
proteinuria.

4- IgA nephropathy

5- Analgesic nephropathy

Answer & Comments

Answer: 5- Analgesic nephropathy

[ Q: 444 ] MRCPass - Nephrology

A 45 year old patient with chronic
hepatitis C has now developed hypotension
and oliguria. His liver and renal function tests
suggest hepatorenal syndrome.

Which of the following measures is likely to
improve his prognosis?

1- Renal transplantation

2- Liver transplantation

3- TIPSS

4- Loop diuretics

5- Haemodialysis

Analgesic nephropathy is usually a result of
prolonged or chronic ingestion of analgesics,
especially over-the-counter (OTC) medications
that contain phenacetin or acetaminophen
and nonsteroidal antiinflammatory drugs
(NSAIDs) including aspirin or ibuprofen. The
ingestion may have been excessive over a
period of years. This frequently occurs as a
result of self-medication, often for some type
of chronic pain.

There is interstitial nephritis and renal
papillary necrosis, eventually leading to acute
renal failure or chronic renal failure. There
may be haematuria but minimal or no
proteinuria.

Answer & Comments

Answer: 2- Liver transplantation

Hepatorenal syndrome is due to reduced renal
cortical perfusion, caused by accumulation of
toxins which would normally be cleared by the
liver. Liver transplantation is the only option
which would provide a resolution of this
problem.

[ Q: 445 ] MRCPass - Nephrology

A 70 year old woman is referred for
investigation of a creatinine of 250
micromol/l. She mentioned several episodes
of haematuria. She has a long history of low
back pain treated with a combination of
painkillers. An ultrasound shows two irregular
shaped kidneys sized 8.5 and 9 cm.

Which of the following is the most likely?

1- Minimal change nephropathy

2- Diabetic nephropathy

3- Membranous glomerulonephritis

[ Q: 446 ] MRCPass - Nephrology

A 65 year old man is being
considered for dialysis.

Which of the following suggests that the
patient should be considered for CAPD rather
than haemodialysis?

1- Hypertension

2- Severe congestive cardiac failure

3- Recent inguinal surgery

4- COPD

5- Glomerulonephritis

Answer & Comments

Answer: 2- Severe congestive cardiac failure

Severe cardiac failure often leads to
circulatory compromise (hypotension) during
haemodialysis, hence such a patient would be
better dialysed by CAPD.

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[ Q: 447 ] MRCPass - Nephrology

A 30 year old intravenous drug user
who is HIV positive, presents with
oedematous ankles and breathlessness.

There is no history of diabetes. He has a urea
of 13 pmol/l, creatinine of 140 pmol/l. AST is
25 U/l, ALP is 120 U/l, bilirubin 18 pmol/l and
albumin is 25 g/l. A 24 hour urine protein is
5.5g in total.

Which of the following is the likely diagnosis?

1- Focal segmental glomerulosclerosis

2- Minimal change nephropathy

3- Membranoproliferative glomerulonephritis

4- Nephritic syndrome

5- Post streptococcal glomerulonephritis

Answer & Comments

Answer: 1- Focal segmental glomerulosclerosis

Focal segmental glomerulosclerosis is
commonly associated with HIV positive
patients and in view of the history this should
be excluded. The other causes of nephrotic
syndrome are minimal change,
membranoproliferative, and membranous
glomerulonephritis.

Focal segmental glomerulosclerosis (FSGS). An
area of collagenous sclerosis runs across the
middle of this Glomerulus

[ Q: 448 ] MRCPass - Nephrology

A 15 year boy presents with Henoch
Schonlein purpura related renal impairment
with a creatinine of 200 pmol/l.

What is the likely outcome in the long term?

1- Intermittent haematuria

2- Normal renal function

3- Recurrent urinary tract infections

4- Renal scarring

5- Progression towards renal cell carcinoma

Answer & Comments

Answer: 2- Normal renal function

Henoch Schonlein Purpura causes a nephritis
which is related to IgA deposition and
vasculitis. It is self limiting and the long term
prognosis is good, with likely recovery of renal
function.

[ Q: 449 ] MRCPass - Nephrology

A 60 year old man presents with
severe pain in his left loin radiating to the left
groin. Bedside testing of urine demonstrates
haematuria. Abdominal ultrasound does not
demonstrate any abnormality and X-ray KUB
does not show any visible stones.

Which form of calculus might the patient
have?

1- Calcium oxalate stone

2- Cystine stone

3- Uric acid stone

4- Triple phosphate stone

5- Calcium phosphate stone

Answer & Comments

Answer: 3- Uric acid stone

Radiopaque stones are: Calcium oxalate,
calcium phosphate, triple phosphate, cystine
stones.

Radiolucent stones are: Uric acid, xanthine
stones.

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[ Q: 450 ] MRCPass - Nephrology

A 45 year old man presents with
recurrent sinusitis for over a year and
occasionally noticed a rash on his chest.

Routine blood tests show that he has a serum
urea of 14 mmol/l and creatinine of 180
micromoles/I.

Which of the following is the most likely?

1- Minimal change nephropathy

2- Systemic vasculitis

3- Membranous glomerulonephritis

4- Goodpasture's syndrome

5- Focal segmental glomerulosclerosis

Answer & Comments

Answer: 2- Systemic vasculitis

This patient is likely to have vasculitis related
to Wegener's granulomatosis.

Sinusitis can arise from involvement of the
nasal tract and sinuses in the Wegener's
pattern of the disease.

Often a patient with systemic vasculitis will
have a long history of indolent disease, but
will then present late with severe aggressive
disease. Serum anti-neutrophil cytoplasmic
antibodies (ANCA) and antibodies against the
ANCA antigens myeloperoxidase and
proteinase 3 may be positive.

[ Q: 451 ] MRCPass - Nephrology

A 57 year old man has presented
with chest pain and pulmonary oedema. He is
managed as acute coronary syndrome. He did
not tolerate a GTN infusion as his blood
pressure was 85/60 but improved with
frusemide and his blood pressure stabilized.
An ACE-inhibitor was held off due to renal
impairment. He is coincidentally found to have
a chest infection, his blood cultures grew
streptococci and he was treated with
augmentin. His blood tests on admission show

a creatinine of 145 pmol/l rising up to
190pmol/ and then 250pmol/l the day after.

What is the likely cause of renal failure?

1- Urinary tract infection

2- Acute tubular necrosis

3- Interstitial nephritis due to augmentin

4- Post streptococcal glomerulonephritis

5- Renal artery stenosis

Answer & Comments

Answer: 2- Acute tubular necrosis

A rapid rise in creatinine following periods of
hypotension is most commonly due to acute
tubular necrosis. Acute tubular necrosis or
(ATN) involves the death of tubular cells that
form the tubule that transports urine to the
ureters while reabsorbing 99% of the water.
Tubular cells continually replace themselves
and if the cause of ATN is removed then
recovery is likely.

^ [ Q: 452 ] MRCPass - Nephrology

fi -

# A 65 year old man has hypertension.
On examination of his abdomen a bruit is
audible in the epigastrium.

Urinalysis shows : Proteins ++ Abdominal
ultrasound reveals a difference in size
between the two kidneys of 2.0 cms in length.

What is the likely diagnosis?

1- Glomerulonephritis

2- Nephritic syndrome

3- Renal artery stenosis

4- Phaeochromocytoma

5- Fibrous dysplasia

Answer & Comments

Answer: 3- Renal artery stenosis

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Hypertension, renal bruit and a difference in
renal sizes are suggestive of renal artery
stenosis.

[ Q: 453 ] MRCPass - Nephrology

A 45 year old man has a history of
hypertension. He now presents with frank
haematuria which has been present for 6
months. His blood results show a urea of 16
mmol/I and creatinine 180 micromoles/l.

Which of the following is the most likely
diagnosis?

1- Focal segmental glomerulosclerosis

2- IgA nephropathy

3- Acute tubular necrosis

4- Nephritic syndrome

5- Wegener's granulomatosis

Answer & Comments

Answer: 2- IgA nephropathy

IgA nephropathy is the commonest
glomerulonephritis worldwide. IgA
nephropathy or Berger's disease is a
clinical/pathological entity defined by the
presence of macroscopic or microscopic
hematuria and mesangial IgA deposits. Signs
and symptoms include proteinuria, nephrotic
syndrome, acute nephritis, malignant
hypertension, chronic renal failure, and acute
renal failure.

Proteinuria is typically within the mild range.
There is a 2:1 male predominance. Findings on
renal biopsy are characteristic. In all patients,
IgA is present and is deposited mainly in the
mesangium of the glomerular tuft. Other
immunoglobulins and complement, especially
C3, are often found in a mesangial pattern.

[ Q: 454 ] MRCPass - Nephrology

A 16 year old boy has had
progressive high tone deafness since
childhood. Investigations reveal:

urea 27 pmol/l

creatinine 310 pmol/l

Urine dipstick: blood + and protein ++

Which one of the following is most likely?

1- Wegener's granulomatosis

2- Tuberous sclrerosis

3- Alports syndrome

4- Sarcoidosis

5- Von Hippel Lindau disease

Answer & Comments

Answer: 3- Alports syndrome

Classic Alport's syndrome is an X linked
disorder characterised by a triad of
progressive hematuric nephritis, progressive
perceptive high-tone hearing loss, and ocular
signs (lenticonus and cataracts). There is
associated nephrotic syndrome in 30% of
patients. Average progression to end stage
renal failure is 30 years.

[ Q: 455 ] MRCPass - Nephrology

A 70 year old male with a three
month history of constitutional symptoms
including weight loss, night sweats, fatigue
and malaise presents with rapidly progressive
acute renal failure, hemoptysis and diffuse
bilateral pulmonary infiltrates.

Biopsy demonstrates a pauci-immune focal
segmental proliferative, necrotizing and
sclerosing glomerulonephritis with crescent
formation and a superimposed necrotizing
and granulomatous arteritis involving small
intrarenal arteries.

What is the likely diagnosis?

1- Polyarteritis nodosa

2- Anti GBM disease

3- Post streptococcal glomerulonephritis

4- Interstitial nephritis

5- Wegener's granulomatosis

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Answer & Comments

Answer: 5- Wegener's granulomatosis

secondary to increased erythropoietin
production.

The clinicopathologic differential diagnosis
includes predominantly the microscopic form
of polyarteritis nodosa (polyarteritis nodosa
with glomerular involvement) and Wegener's
granulomatosis. The presence of extrarenal
(pulmonary) involvement and granulomatous
vasculitis favors Wegener's granulomatosus.

[ Q: 457 ] MRCPass - Nephrology

A 52 year old man with chronic renal
failure has been on EPO injections 3 times a
week for several years.

Which one of the following is o side effect of
erythropoietin therapy?

Crescentic glomerulonephritis or rapidly
progressive glomerulonephritis (RPGN) is a
term given to a diverse group of diseases
which all have cresents present within the
glomerular tuft. These include primary or
renal limited (so-called idiopathic) crescentic
glomerulonephritis, anti-glomerular basment
membrane(anti-GBM) antibody diseases, and
systemic disorders. Light microscopic
examination typically shows at least 30% of
the glomeruli involved by crescents.

[ Q: 456 ] MRCPass - Nephrology

A 35 year old man presents with
hypertension. On examination he had
palpable kidneys and abdominal ultrasound
shows bilaterally enlarged cystic kidneys.

Which of the following features is likely to be
associated?

1- Testicular atrophy

2- Nail dystrophy

3- Mitral stenosis

4- Polycythaemia

5- Short stature

Answer & Comments

Answer: 4- Polycythaemia

In adult polycystic kidney disease, the most
common presentation is a palpable mass,
hypertension, abdominal pain, and hematuria.
Hypertension often predates renal failure.
Polycythemia is a rare but known association

1- Hypokalaemia

2- Anaemia

3- Seizures

4- Iron overload

5- Osteoporosis

Answer & Comments

Answer: 3- Seizures

EPO therapy may lead to hypertension and
seizures. Other side effects of treatment with
erythropoietin include hyperkalaemia in
uraemic patients, increased PCV,
thrombocythaemia, shunt thrombosis, iron
deficiency and urticaria.

[ Q: 458 ] MRCPass - Nephrology

A 55 year old man presents with
chest pain and is thrombolysed for an acute
myocardial infarction. His blood pressure was
85/40 for several hours on admission. Two
days later his blood tests show a urea of 22
mmol/I and creatinine of 300 pmol/l (U+Es
were normal on admission).

What would a renal biopsy show?

1- Positive antibody to fibrinogen

2- Thickened capillary loops

3- Loss of tubular cells

4- IgG deposition in the basement membrane

5- IgA mesangial deposits

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Answer & Comments

Answer: 3- Loss of tubular cells

Due to hypoperfusion, acute tubular necrosis
may occur. This would show necrosis or loss of
tubular cells.

The epithelium of the tubules seen here is
ragged from undergoing necrosis with acute
tubular necrosis (ATN) from ischemia.

[ Q: 459 ] MRCPass - Nephrology

A 65 year old man has renal bruits,
renal impairment and hypertension.

Which one of the following tests is most
appropriate?

1- Intravenous urography

2- Renal DTPA nuclear scan

3- Renal DMSA nuclear scan

4- Renal ultrasound scan

5- Magnetic resonance angiography (MRA) of
renal arteries

Answer & Comments

Answer: 5- Magnetic resonance angiography
(MRA) of renal arteries

For renal artery stenosis, MRA remains the
best investigation with high sensitivities and
specificities.

[ Q: 460 ] MRCPass - Nephrology

A 50 year woman who is on
peritoneal dialysis has a plasma potassium of
6.5 mmol/I.

Which of the following should she avoid in the
diet?

1- Cereal

2- Yoghurt

3- Broccoli

4- Carrots

5- Tomato

Answer & Comments

Answer: 5- Tomato

All meats, poultry and fish are high in
potassium. Others are : Apricots (fresh more
so than canned), Avocado, Banana,
Cantaloupe, Honeydew , Kiwi, Lima beans,
Milk, Oranges and orange juice, Potatoes,
Prunes, Spinach, Tomatoes, Vegetable juice.
Winter squash

[ Q: 461 ] MRCPass - Nephrology

A 27 year old man is admitted with
pains radiating from his right loin to the groin.
He also has haematuria. He gives a history of
previous urinary tract infections. Clinical
examination is unremarkable. Investigations
are as follows:

Serum Sodium 139 mmol/L
Potassium 2.8 mmol/L
Urea 6.6 mmol/L
Creatinine 105 micromoles/L
Chloride 116 mmol/l
Bicarbonate 15 mol/L

Which of the following would help treat the
condition?

1- Probenecid

2- Ciprofloxacin

3- Erythropoietin

4- Cyclophosphamide

5- Sodium bicarbonate

Answer & Comments

Answer: 5- Sodium bicarbonate

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The patient presented with a history of renal
colic and previous urinary tract infections and
investigations reveal a normal anion gap
acidosis. These features suggest a diagnosis of
distal renal tubular acidosis. Sodium
bicarbonate is effective in decreasing the
acidosis.

[ Q: 462 ] MRCPass - Nephrology

A 25 year old has a family history of
adult polycystic kidney disease.

Whot is the best test to exclude polycystic
kidney disease in this woman?

1- Genetic linkage analysis

2- Renal ultrasound

3- Intravenous urogram

4- Urinalysis

5- Isotope renography

Answer & Comments

Answer: 2- Renal ultrasound

Ultrasonography with the criteria of more
than 2 cysts in < 30 years age group is
diagnostic of adult polycystic kidney disease.
Genetic linkage analysis can be done as well
(but less practical) to screen for PKD1
mutation on chromosome 16 and a PKD2
mutation on chromosome 4.

[ Q: 463 ] MRCPass - Nephrology

A 55 year old man who has been on
haemodialysis for 20 years has progressive
dementia.

Which one of the following is most likely to
have caused this?

1- Urea disequilibrium

2- Small vessel ischaemia

3- Aluminium toxicity

4- Amyloidosis

5- Alzheimer's disease

Answer & Comments

Answer: 3- Aluminium toxicity

Aluminium has been implicated in 'dialysis
dementia'. Dialysis dementia may be part of a
multisystem disorder which includes vitamin D
resistant osteomalacia, proximal myopathy,
and non-iron deficient, microcytic,
hypochromic anaemia. The use of aluminium
free dialysate may arrest, or even improve,
the established case. Desferrioxamine
infusions (aluminium chelator) are the
mainstay of treatment of dialysis dementia,
improving up to 70% of patients, sometimes
to normal.

[ Q: 464 ] MRCPass - Nephrology

A 50 year old woman has
investigations for recurrent renal calculi.

A 24 hour urine collection revealed:

calcium 18 mmol/24 hours (2-7)

oxalate 180 mmol/24 hours (90-450)

uric acid 2.8 mmol/24 hours (1.5-4.4)

citrate 2 mmol/24hours (0.3-0.4)

Which form of treatment is likely to be
successful?

1- Penicillamine

2- Thiazide diuretics

3- Insulin

4- Aluminium phosphate

5- Probenecid

Answer & Comments

Answer: 2- Thiazide diuretics

Hypercalciuria is the most common
identifiable cause of calcium kidney stone
disease. The other significant causes are
hyperoxaluria, hyperuricosuria, low urinary
volume, and hypocitraturia.

Hypercalciuria is defined as urinary excretion
of more than 250 mg (6.2 mmol/24 h) or more

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than 275-300 mg (7.5 mmol/24 h) of calcium
per day for men while on a regular,
unrestricted diet.

Thiazides currently are the mainstay of
medical therapy for hypercalciuria.
Orthophosphate therapy can also be used as a
preventive treatment for kidney stones.

3- Reduced d dimer levels

4- Reduced antithrombin III activity

5- Reduced fibrinogen concentration

Answer & Comments

Answer: 4- Reduced antithrombin III activity

[ Q: 465 ] MRCPass - Nephrology

A 40 year old man presents with
microscopic haematuria and hypertension.
Ultrasound scan of his kidneys shows several
cysts. He has a family history of a brain
tumour (father) and an aunt had renal failure
and deafness.

Which of the following conditions is likely?

1- Neurofibromatosis

2- Von Hippel Lindau

3- Alport's syndrome

4- Renal tubular acidosis type II

5- Scleroderma

Answer & Comments

Answer: 2- Von Hippel Lindau

von Hippel Lindau disease is transmitted as an
autosomal dominant condition.

Affected individuals may have renal cysts,
Clear cell renal cell carcinoma (CCRCC), retinal
angiomas, central nervous system
haemangioblastoma, phaeochromocytoma.

[ Q: 466 ] MRCPass - Nephrology

A 60 year woman has bilateral sw
ollen calves and ankles, with the left calf more
painful and sw ollen. A 24 hr urine protein was
8g/day.

Which could explain these findings?

1- Factor VIII deficiency

2- Reduced concentration of Von Willebrand's
factor

This patient has nephrotic syndrome, and also
a probable left DVT. The most likely cause is
nephrotic syndrome related reduced
antithrombin III activity. Acquired AT-III
deficiency causes include chronic liver disease,
and protein loss due to ascites or nephrotic
syndrome.

[ Q: 467 ] MRCPass - Nephrology

An 70 year old man was found on
the floor of his hallw ay by his neighbour. On
assessment in casualty, his GCS was 11/15,
and he had a dense right hemiparesis.

His blood results are:

Na 145 mmol/I

K 6.2 mmol/I

Bic 22 mmol/I

Urea 20 umol/l

Creat 235 umol/l

Glu 7.5 mmol/I

Calcium (total) 1.72 mmol/l

Phosphate 1.6 mmol/l

Bili 12 umol/l

Aik phos 210 U/l

Albumin 35 g/l

WCC 12 x 10 9 /L

Hb 12.5 g/dl

PI 350 x 10 9 /L

Urine Blood +++, protein negative

Urine microscopy - No WC, No RBCs. No
organisms seen

The most likely cause is:

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1- Amyloidosis

Answer & Comments

2- Porphyria cutanea tarda

3- Pyelonephritis

4- Rhabdomyolysis

5- Renal tubular acidosis type II

Answer & Comments

Answer: 4- Rhabdomyolysis

Raised CK (though not given) and renal failure
makes rhabdomyolysis likely. Presence of
urine myoglobin will cause a false positive
urine dipstick to blood.

[ Q: 468 ] MRCPass - Nephrology

A 49 year old man with a history of
heavy alcohol abuse and no other significant
past medical problems was admitted for
treatment of alcoholic hepatitis. He had no
know n history of liver or kidney disease until
1 month before admission, when jaundice
developed.

Initially, he received treatment and follow -up
as an outpatient but was then admitted for
inpatient care when his mental status
deteriorated. He had jaundice, tense ascites,
severe leg edema, and mild to moderate
encephalopathy.

His blood tests revealed: urea 32 pmol/l,
creatinine 480 pmol/l, ALT 180 (5-35) U/l, AST
140 (1-31) U/l, ALP 360 (20-120) U/l, Bilirubin
45 (1-22) pmol/l, Albumin 30 (37-49) g/l. Urine
sodium is 8 mmol/l.

Which of the following should he be treated
with ?

1- Normal saline infusion

2- Terlipressin

Answer: 2- Terlipressin

The diagnosis is hepatorenal syndrome.
Treatment that combines peripheral
vasoconstricting medications or splanchnic
vasoconstricting medications (e.g. midodrine),
with a volume expander (eg, albumin) has
show n significant short-term efficacy.
Promising results have been reported in
studies and case reports with agonists of
vasopressin VI receptors, such as terlipressin,
which predominantly act on the splanchnic
circulation. Such treatment is designed to
decrease the effects of intravascular
hypovolemia.

^ [ Q: 469 ] MRCPass - Nephrology

# A 60 year man has been on

haemodialysis for 15 years due to diabetic
nephropathy. He now has joint pains in the
shoulders and knees. He has a past medical
history of bilateral carpal tunnel
decompression.

His bloods reveakHb 11 g/dl, ESR 50 mm/hr,
urea 18 pmol/l, creatinine 250 pmol/l, sodium
142 mmol/l, potassium 4.4 mmol/l, Urate 0.6
(< 0.45).

What is the likely diagnosis?

1- Gout

2- Polymyalgia rheumatica

3- Rheumatoid arthritis

4- Calcium pyrophosphate deposition

5- B2 microglobulin amyloidosis

Answer & Comments

Answer: 5- B2 microglobulin amyloidosis

3- ACE inhibitor

4- Thiazide diuretics

The history of joint pains in a dialysis patient
suggests amyloidosis.

5- Renal transplantation

Amyloid deposits composed of b2-
microglobulin is laid down in periarticular
surfaces of joints and can develop

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approximately 10 years after the start of
dialysis.

[ Q: 470 ] MRCPass - Nephrology

A 35 year old lady with SLE presents
significant proteinuria and
hypoalbuminaemia. A renal biopsy confirms
diffuse proliferative glomeronephritis (WHO
Class IV).

with

Which of the following treatment regimes is
recommended?

1- Prednisolone alone

2- Azathioprine alone

3- Azathioprine & Methotrexate

4- Prednisolone & Methotrexate

5- Prednisolone & intravenous
Cyclophosphamide

Answer & Comments

Answer: 5- Prednisolone & intravenous
Cyclophosphamide

Diffuse proliferative glomerulonephritis is the
commonest glomerulonephritis in SLE. There
is mesangial and endothelial cell proliferation,
polymorphonuclear cell infiltrate and granular
subepithelial deposits of C3. It also carries the
worst prognosis with progression towards
renal failure.

The currently recommended therapy is pulse
intravenous corticosteroids in combination
with pulse cyclophosphamide continued for at
least 12 months after remission. Newer
regimes include combinations of prednisolone
and mycophenolate.

[ Q: 471 ] MRCPass - Nephrology

A 22 year old woman has taken an
overdose of multiple drugs.

Haemodialysis is useful in the removal of
which one of the following drugs?

1- Digoxin

2- Amiodarone

3- Paraquat

4- Paracetamol

5- Salicylates

Answer & Comments

Answer: 5- Salicylates

Haemodialysis is useful for salicylates, NSAIDs,
lithium, and in particular, Antifreeze
poisioning. It is not useful for tricyclics,
amiodarone and paraquat, paracetamol and
digoxin, which is mostly tissue bound (use
digoxin binding antibodies).

[ Q: 472 ] MRCPass - Nephrology

A 50 year diabetic patient is on the
following medication:

Metformin lg tds

Gliclazide 80 mg bd

Ramipril 5 mg daily

atenolol 50 mg

Her blood results show :

urea 13 pmol/l

creatinine 190 pmol/l

sodium 138 mmol/I

potassium 4.9 mmol/I

Which of the following medications should be
withdrawn?

1- Gliclazide

2- Metformin

3- Atenolol

4- Ramipril

5- None of the above

Answer & Comments

Answer: 2- Metformin

The half life of metformin is prolonged in renal
impairment. There is a risk of lactic acidosis.

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Patients with a creatinine above 150 pmol/l
should have metformin discontinued.

Answer & Comments

Answer: 1- Colostomy

[ Q: 473 ] MRCPass - Nephrology

A 60 year old man has chronic renal
failure due to hypertension. His plasma
creatinine reading is 300 pmol/L, potassium
level is 5.2 mmol/L, urea 17.0 mmol/L,
phosphate 1.7 mmol/L, calcium 2.15 mmol/L,
haemoglobin 10.0 g/dL. He has symptoms of
lethargy and breathlessness on exertion.

Recent or prospective abdominal surgery is a
contraindication to CAPD.

[ Q: 475 ] MRCPass - Nephrology

A 60 year old man has type II
diabetes and hypertension. He is feeling
lethargic and is seen in the general medical
clinic.

Which of the following treatments would be
appropriate?

1- Erythropoietin

2- ACE inhibitor

3- Alfacalcidol at 0.25 meg per day

4- Haemodialysis

5- Phosphate restriction

Answer & Comments

Answer: 1- Erythropoietin

This patient would benefit from recombinant
human EPO to correct his anaemia. Other
causes of anaemia should be excluded first
with haematinics.

Investigations reveal:

Na 140 mmol/I,

K 5.5 mmol/I,

Urea 18 mmol/l,

Cr 220 pmol/1

Ultrasound of kidneys show : Left kidney 8.2
cm length, Right kidney 8.9 cm length.

What is the likely cause of the renal failure?

1- Acute tubular necrosis

2- Wegener's granulomatosis

3- Berger's disease

4- Cholesterol emboli

5- Renovascular disease

[ Q: 474 ] MRCPass - Nephrology

A 60 year old lady with multiple
medical problems is being considered for renal
dialysis.

Which one of the following is an absolute
contraindication to choosing continuous
ambulatory peritoneal dialysis?

1- Colostomy

2- Polycystic kidneys

3- Heart failure

4- Previous ovarian surgery

5- Diabetes

Answer & Comments

Answer: 5- Renovascular disease

The vascular risk factors and asymmetrical
atrophic kidneys suggest renovascular disease.
A magnetic resonance angiogram or digital
subtraction angiography should be performed.

[ Q: 476 ] MRCPass - Nephrology

A 40 year old man has been unwell
for several weeks with lethargy. His BP is
150/95 mmHg. Urinalysis shows no glucose,
blood, ketones, nitrite but has protein +++.

A 24 hour urine collection shows protein of 4
g. His serum creatinine is 280 micromol/L,

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urea is 27 mmol/L. His hepatitis B surface
antigen is positive.

Which of the following diseases is likely?

1- Minimal change glomerulonephritis

2- Post streptococcal glomerulonephritis

3- Membranous glomerulonephritis

4- Acute nephritic syndrome

5- Diabetic nephropathy

Answer & Comments

Answer: 3- Membranous glomerulonephritis

Whot is the likely diagnosis?

1- Ischaemic nephropathy

2- Analgesic glomerulonephritis

3- Analgesic interstitial nephritis

4- Minimal change nephropathy

5- IgA nephropathy

Answer & Comments

Answer: 1- Ischaemic nephropathy

The likely diagnosis is renovascular disease
due to the small kidney size.

Membranous nephropathy is caused by
thickening of the capillary wall of the
glomerular basement membrane (the deepest
membrane) by immune complexes.

Causes of membranous glomerulonephritis
are Hepatitis B, malaria, malignant tumors,
non-Hodgkin's lymphoma, systemic lupus
erythematosus, syphilis, gold, mercury,
penicillamine.

The goal of treatment is to minimize
symptoms and slow the progression of the
disease. Often, corticosteroids or
immunosuppressive medications may be used
to reduce symptoms and progression of the
disorder. Medications to treat symptoms may
include antihypertensive and diuretic and
cholesterol low ering agents.

[ Q: 477 ] MRCPass - Nephrology

A 65 year old lady has investigations
for renal impairment (creatinine 220 umol/l).
She has a previous history of hypertension,
peripheral vascular disease and osteoarthritis.
She has been taking diclofenac for 6 years and
penicillamine for the past 2 years (the drug
was stopped 1 year ago).

Investigations show:

Urine : protein +, blood -ve

Ultrasound of kidneys : right 7.8 cm, left 8 cm
in length.

There is only 1+ Proteinuria. The other clue is
the history of hypertension. The normal length
of kidneys is between 10-13 cm.

[ Q: 478 ] MRCPass - Nephrology

A 28 year old man was found to have
acute renal failure.

Which of the following is an indication for
urgent dialysis in renal failure?

1- Breathlessness

2- Potassium of 6.5 mmol/I

3- Glomerulonephritis

4- Haematuria

5- Pericardial effusion

Answer & Comments

Answer: 5- Pericardial effusion

Indications for dialysis are:

uraemia pericarditis with effusion
pulmonary oedema
significant hyperkalaemia (>7) with
evidence of ECG changes
rapidly rising urea and creatinine

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^ [ Q: 479 ] MRCPass - Nephrology

/ -

# A 45 year woman presents with

ankle oedema. Her blood pressure was 120/70
mmHg.

Investigations show:

Creatinine 95 umol/L, Albumin 22 g/L,
Urinalysis shows blood - protein ++++, Urinary
protein excretion 8g /24hr.

Answer & Comments

Answer: 5- Calcium gluconate

The important management step is to provide
cardioprotection in the form of calcium
gluconate. Following this the patient should
have insulin and dextrose, as well as
consideration for haemodialysis if the
potassium does not improve.

What is the best management step?

1- ACE inhibitor

2- Frusemide

3- Insulin

4- Steroids

5- High protein diet

[ Q: 481 ] MRCPass - Nephrology

A 60 year old man has oliguria,
peripheral oedema and breathlessness. He
also gives a history of intermittent
haemoptysis and dyspnoea over several
months. There is no other significant past
medical history.

Answer & Comments

Answer: 4- Steroids

This patient has nephrotic syndrome as
indicated by proteinuria, hypoalbuminuria,
oedema (and hyperlipidaemia). High dose
steroids should be the first line therapy e.g.
prednisolone.

On examination he is oedematous, cyanosed,
tachypnoeic and there are widespread
inspiratory crackles throughout the lung fields.
Investigations are as follow s: Urine - Protein
++, Blood ++, Immunology: Anti glomerular
basement membrane antibody positive,

The renal biopsy is likely to show :

1- Minimal change glomerulonephritis

[ Q: 480 ] MRCPass - Nephrology

A 42 year old man has presented
with palpitations and dizziness. Upon
investigation he has the following results:

sodium 132 mmol/l

potassium 7.6mmol/l

urea 22 pmol/l

creatinine 360 pmol/l

What should be the initial management?

1- Frusemide

2- Haemodialysis

3- Sodium bicarbonate

4- Insulin and dextrose

2- Membranoproliferative glomerulonephritis

3- Focal segmental glomerulosclerosis

4- Crescentic glomerulonephritis

5- Membranous glomerulonephritis

Answer & Comments

Answer: 4- Crescentic glomerulonephritis

The diagnosis is Goodpasture's syndrome.
Initially there is a focal proliferative
glomerulonephritis and it later develops into a
proliferative crescentic glomerulonephritis.
The proliferative changes are frequently
associated with epithelial crescent formation
and necrosis.

5- Calcium gluconate

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This immunofluorescence pattern shows
positivity with antibody to IgG. There is a
smooth, diffuse, linear pattern that is
characteristic for deposition of glomerular
basement membrane antibody with
Goodpasture syndrome.

[ Q: 482 ] MRCPass - Nephrology

A 55 year man has nephrotic
syndrome diagnosed recently. His
investigations show an albumin of 20 g/L,
Total cholesterol of 9 mmol/l, 24 hour urine
reveals 4.5g protein excretion. A renal biopsy
shows focal segmental glomerulosclerosis.

Which one of following is most likely to
preserve renal function?

1- Bendrofluazide

2- Salt restriction

3- Lisinopril

4- Atorvastatin

5- Aspirin

Answer & Comments

Answer: 3- Lisinopril

In Focal Segmental Glomerulosclerosis (FSGS),
ACE inhibitors usually reduce proteinuria and
lipemia, and may slow the progression tow
ards renal disease.

[ Q: 483 ] MRCPass - Nephrology

A 32 year old woman has loin pains
and haematuria. She has a family history of
polycystic kidney disease.

Which one of the following tests should be
performed?

1- Intravenous urogram

2- Renal ultrasound

3- Genetic testing

4- Isotope renography

5- Urine dipstick

Answer & Comments

Answer: 2- Renal ultrasound

Renal ultrasound is the simplest test. Genetic
testing can also be done (PKD1 on
chromosome 16, PKD2 on chromosome 4).

[ Q: 484 ] MRCPass - Nephrology

A 50 year old man has end stage
renal failure due to diabetes. He receives 4
hours of haemodialysis, 3x weekly.

His pressure is 180/105 mmHg predialysis and
160/90 mmHg postdialysis. Predialysis bloods
show:

Hb lOg/dL

sodium 132 mmol/l

potassium 6.5 mmol/L

urea 45 mmol/l

creatinine 1125 umol/L

calcium (corrected) 2.15 mmol/L

phosphate 1.2 mmol/l

Whot is the best management step?

1- Aluminium phosphate binders

2- 1-alfacalcidol supplements

3- Increase length of haemodialysis

4- Erythropoietin supplements

5- Calcium gluconate iv

Answer & Comments

Answer: 3- Increase length of haemodialysis

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The high urea and creatinine, as well as
hypertension suggests there is more room for
dialysis. Although EPO or vit D supplements
are probably beneficial, longer dialysis
sessions would help clear the fluid overload
and reno-toxins.

striking vacuolar change in the renal tubular
cells, with large nodular aggregates of foamy
cells. Intracellular accumulation of several
glycosphingolipids was suspected.

Which one of the following is likely?

1- Tuberculosis

[ Q: 485 ] MRCPass - Nephrology

A 40 year old patient with renal
calculi has further investigation.

High urinary levels of the following substances
predispose to urinary tract stone formation,
EXCEPT FOR:

1- Cystine

2- Citrate

3- Calcium

4- Urate

5- Oxalate

Answer & Comments

Answer: 2- Citrate

Calcium, oxalate, cystine and urate are all
stone-forming substances, so high urinary
levels promote stone formation. Low urinary
citrate levels promote stone formation.

[ Q: 486 ] MRCPass - Nephrology

A 30-year-old woman presented
with a history of nephrotic syndrome
diagnosed when she was 4 years old.

There was no family history of renal disease.
An initial renal biopsy performed showed
minimal-change disease.

She was treated with steroids and was
determined to be steroid-dependent.
Subsequent trials of cyclosporine and
cyclophosphamide failed to improve her
condition and she was referred for additional
evaluation.

She has a second renal biopsy. Light
microscopic examination showed a patchy but

2- Diabetic nephropathy

3- Anderson Fabry disease

4- Glycogen storage disease

5- Fibromuscular dysplasia

Answer & Comments

Answer: 3- Anderson Fabry disease

Inheritance of Anderson Fabry disease is
usually X linked recessive. A rare, inherited
metabolic disease in which a glycolipid,
ceramide trihexoside, accumulates in blood
vessels, as well as in numerous tissues and
organs. The excessive amounts present in the
kidneys and other organs impairs their
function. It is due to the absence of alpha
galactosidase A.

Patients present with the skin lesions
(angiokeratoma corporis diffusum), small red
spots seen on the lower abdomen, thighs and
scrotum, corneal opacities, episodes of fever,
primary aparasthesia of the extremities and
peripheral oedema and renal failure. It is
prevalent in males, who present with full-blow
n syndrome. Females are more likely to
present with a partial form.

Angiokeratoma corporis diffusum

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ti -

# A 50 year old woman has ankle
oedema.

Urine dipstick analysis shows +++ Protein.

Blood tests show:

creatinine 90 micromol/l

urea 8 mmol/l

albumin 20g/l

A renal biopsy shows foot process fusion on
the electron microscopy.

Which of the following agents should be
started?

Ferrtin concentration : decreased in three
months from upper limit of normal to lower
limit of normal

What is the cause for the anemia?

1- Inadequate erythropoietin

2- Osteitis fibrosa cystica

3- Inadequate dialysis

4- Iron deficiency

5- Hyperparathyroidism

Answer & Comments

Answer: 4- Iron deficiency

1- Infliximab

2- Prednisolone

3- Clopidogrel

4- Azathioprine

5- Ciclosporin

Answer & Comments

Answer: 2- Prednisolone

The diagnosis is minimal change
glomerulonephritis. Initial therapy is with
prednisolone rather than Azathioprine.
Retraction of the epithelial foot processes is
observed consistently in patients with MCD.
This is, at times, described as foot-process
fusion and results from disordered epithelial
cell structure with withdraw al of the dendritic
process. This leads to the loss of the normal
charge barrier such that albumin selectively
leaks out and proteinuria ensues.

[ Q: 488 ] MRCPass - Nephrology

A 51 year old man was on dialysis for
renal failure. He was on erythropoietin.
Investigations show:

Hb 8 g/dl

Parathyroid hormone 15 (0.8-8) pmol/l

There are many causes of decreased
responsiveness to erythropoietin in patients
with chronic renal failure. The most common
is insufficient iron to meet the demands of
increased erythrocyte production. Other
factors that can attenuate the response
include aluminum toxicity, infection,
inflammation, and folic acid deficiency.

[ Q: 489 ] MRCPass - Nephrology

A 18 year old male is admitted with a
history of haematuria and facial sw elling.
Since two weeks ago he complained of a
sorethroat which was very bad and persistent.
On examination there is facial and ankle
oedema.

His blood pressure is marginally elevated at
150/90. Investigations show haematuria and
red cell casts. Blood urea is elevated. C 3 and C
4 levels are reduced. Abdominal ultrasound
shows normal sized kidneys.

What is the diagnosis?

1- Ig A nephropathy

2- Mesangiocapillary glomerulonephritis

3- Post streptococcal acute nephritic
syndrome

4- Renal artery stenosis

5- Focal segmental glomerulonephritis

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Answer & Comments

Answer: 3- Post streptococcal acute nephritic
syndrome

In post streptococcal acute nephritic
syndrome,

pontaneous improvement usually occurs and
the aim of treatment is to prevent
complications such as pulmonary oedema,
uraemia or hypertensive encephalopathy
whilst awaiting spontaneous improvement in
renal function.

Penicillin may help active bacterial infection of
the throat.

[ Q: 490 ] MRCPass - Nephrology

An 60 year old woman was brought
to the emergency department with
hypertension and abdominal pain.

Physical examination and initial laboratory
work-up were unremarkable; except for
severe abdominal tenderness and elevated
lactate dehydrogenase.

A CT scan showed a hypodense, triangle¬
shaped area in the right kidney suggestive of
renal infarction. Renal duplex scanning
revealed a focal increase of flow velocities
followed by turbulence in multiple segments
of the right renal artery. Arteriography
showed multiple lesions in a "string of beads"
pattern and a parenchymal filling defect.

Whot is the diagnosis?

1- Polyarteritis nodosa

2- Wegener's granulomatosis

3- Sarcoidosis

4- Adult polycystic kidney disease

5- Fibromuscular Dysplasia

Answer & Comments

Answer: 5- Fibromuscular Dysplasia

Fibromuscular Dysplasia is an uncommon

vascular disease, which results in arterial

dilation and narrowing of vessel segments.
Definitive diagnosis can be made by selective
renal arteriographs and bilateral renal vein
and systemic venous renin measurements.

Fibromuscular dysplasia (FMD), is a

developmental lesion of unknow n etiology

which can affect multiple vessels. It consists of
areas of heaped up intima, media, and
adventitia alternating with areas of medial
destruction, the latter resulting in small focal
aneurysms. The disorder can be progressive
and affects females greater than males in a
ratio of 3:1. It more commonly affects middle
aged patients.

Image shows a diffusely beaded appearance
of the right main renal artery to the level of

the branch vessels.

[ Q: 491 ] MRCPass - Nephrology

A 35 year old woman with a 25-year
history of diabetes treated with insulin is
found to have lg proteinuria per 24 hour and
a creatinine 200 pmol/l. He has significant
peripheral oedema. Blood pressure is 145/85
mm Hg.

HbAlC is 8%.

In order to preserve renal function, which of
the following is the most important step?

1- Commence frusemide

2- Strict restriction of dietary phosphate

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3- Strict diabetic control aiming for HbAlc <
7%

4- Commence a beta blocker

5- Commence an ACE inhibitor

Answer & Comments

Answer: 5- Commence an ACE inhibitor

There is clear evidence that ACE inhibition
(enalapril, captopril used in trials) in diabetics
delays progression of renal failure even if they
are normotensive.

[ Q: 492 ] MRCPass - Nephrology

A 19-year-old male is unwell. He has
previously had a history of renal
transplantation 5 years ago. Within three days
of admission he developed acute renal failure
with evidence of haemolytic anaemia and
thrombocytopenia.

A clinical diagnosis of haemolytic uraemic
syndrome was made and he was treated with
plasma exchange.

Which one of the following drugs could have
caused this?

1- Ciclosporin

2- Trimethoprim

3- Prednisolone

4- Amoxycillin

5- Intravenous immunoglobulin

Answer & Comments

Answer: 1- Ciclosporin

Ciclosporin can cause HUS in renal transplant
recipients, especially in those also receiving
rapamycin, which increases tissue
concentrations of ciclosporin.

[ Q: 493 ] MRCPass - Nephrology
A 30 year old African woman

presents with seizures, hypertension, a malar
rash.

Bloods show:

Hb 11 g/dl, WCC 8 x 10 9 /L, platelets 180 x
10 9 /L, urea 22 pmol/l, creatinine 290 pmol/l,
sodium 140 mmol/l, potassium 5 mmol/I, ESR
100 mm/hr, CRP 25 mg/I.

What is the most likely diagnosis?

1- Anti GBM disease

2- Multiple myeloma

3- SLE

4- Wegener's granulomatosis

5- Sickle cell disease

Answer & Comments

Answer: 3- SLE

With the history of renal impairment, raised
ESR, malar flush, SLE is the most likely
diagnosis.

[ Q: 494 ] MRCPass - Nephrology

A 45 year old diabetic gentleman had
a renal biopsy during investigation of
worsening renal failure.

Which of the following is typical of diabetic
nephropathy?

1- Hyaline thrombus formation

2- Mesangial hypercellularity

3- Congo red staining causing green
birefringence

4- Basement membrane spikes

5- Basement membrane thickening and
mesangial widening

Answer & Comments

Answer: 5- Basement membrane thickening
and mesangial widening

The earliest morphologic abnormality in
diabetic nephropathy is the thickening of the

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glomerular basement membrane (GBM) and
expansion of the mesangium due to
accumulation of extracellular matrix. Light
microscopy findings show an increase in the
solid spaces of the tuft, material (diffuse
diabetic glomerulopathy).

4- Ibuprofen

5- Allopurinol

Answer & Comments

Answer: 4- Ibuprofen

Large acellular accumulations also may be
observed within these areas. These are
circular on section and are known as the
Kimmelstiel-Wilson lesions/nodules.

Immunofluorescence microscopy may reveal
deposition of immunoglobulin G along the
GBM in a linear pattern, but this is not
diagnostic. In advanced disease, the mesangial
regions occupy a large proportion of the tuft,
with prominent matrix content. Further, the
basement membrane in the capillary walls (ie,
the peripheral basement membrane) is thicker
than normal.

Diabetic glomerulopathy of Kimmelstiel-

Wilson disease

^ [ Q: 495 ] MRCPass - Nephrology

# A 40 year old woman presents with
sw ollen ankles. Her urine dipstick reveals
protein +++, but no other abnormality. She
has gout and diabetes. Plasma creatinine is
120 micromoles/I and albumin 28g/l.

Which of the following medications would be
most likely to account the sw ollen ankles and
proteinuria?

1- Lisinopril

2- Bendrofluazide

3- Prednisolone

Non-steroidal anti-inflammatory drugs can
cause nephrotic syndrome and interstitial
nephritis.

[ Q: 496 ] MRCPass - Nephrology

A 45 year old woman presents with
high fever, purpura occurring on her arms and
legs, haematuria and renal dysfunction.

Investigation results were:

sodium 135 mmol/I

potassium 4.5 mmol/I

urea 5 mmol/I

creatinine 100 pmol/l

A p-ANCA is positive

Renal biopsy before steroid therapy confirmed
the diagnosis of pauci-immune-type crescentic
glomerulonephritis.

What is the diagnosis?

1- Post streptococcal glomerulonephritis

2- Microscopic polyangitis

3- Temporal arteritis

4- Takayasu's arteritis

5- Behcet's disease

Answer & Comments

Answer: 2- Microscopic polyangitis

P-ANCA (perinuclear staining) is usually due to
myeolperoxidase, and is found in :

microscopic polyarteritis (80%)

idiopathic crescentic GN(65%)

Churg-Strauss Syndrome

polyarteritis nodosa

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Wegener's granulomatosus

3- Iv dextrose (50% 50mls) insulin 15 units

SLE

Although p ANCA can be positive in many
conditions, c ANCA is found more commonly
in Wegener's Granulomatosis.

Treatment of the condition is with high dose
steroids.

[ Q: 497 ] MRCPass - Nephrology

A 40 year old man has a potassium
of 7.5 mmol/I and requires treatment. ECG
shows widened QRS complexes.

Which one of the following agents is
cardioprotective but does not lower
potassium?

1- NSAIDs

2- Salbutamol

3- ACE inhibitors

4- Calcium gluconate

5- Insulin and dextrose

Answer & Comments

Answer: 4- Calcium gluconate

Calcium gluconate is cardioprotective but
does not lower potassium. ECG changes of
hyperkalaemia in progression of severity are
tented T waves, decreased p wave amplitude,
widened QRS complex, sinusoidal waves and
asystole.

[ Q: 498 ] MRCPass - Nephrology

A 50 year old man who presents with
dizziness has broad complexes on the ECG. His
blood gas reveals that his potassium is 8
mmol/l.

Which of the following is the best medical
therapy?

1- Rectal calcium resonium

2- Iv calcium gluconate lOmls 10%

4- Nebulised salbutamol

5- Iv sodium bicarbonate

Answer & Comments

Answer: 2- Iv calcium gluconate lOmls 10%

The first line therapy for cardioprotection is
calcium gluconate.

Following this, insulin and dextrose should be
given.

[ Q: 499 ] MRCPass - Nephrology

A 42 year old man has generalised
oedema. Urine dipstick shows protein +++,
blood -ve.

Which one of the following findings is
suggestive of amyloidosis?

1- Abnormal liver function tests

2- Cryoglobulinaemia

3- Benign monoclonal gammopathy without
myeloma

4- Large numbers of granular casts, fat bodies
and red cells in the urine

5- Selective proteinuria

Answer & Comments

Answer: 3- Benign monoclonal gammopathy
without myeloma

Light chains in the urine suggest deposition
causing amyloidosis (may be either myeloma
or benign monoclonal gammopathy).

Deposits occur in the tongue, nerves or heart.
Cryoglobulinaemia is suggestive of lymphoma
or myeloma. Granular casts, red cell casts and
selective proteinuria suggest

glomerulonephritis.

[ Q: 500 ] MRCPass - Nephrology
A 35 year old man has renal colic.

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Ultrasound of the abdomen confirms renal
calculi. Urinalysis showed typical hexagonal or
benzene crystals.

What is the diagnosis?

1- Calcium oxalate stones

2- Cystinuria

3- Primary oxaluria

4- Calcium carbonate stones

5- Adult polycystic kidney disease

Answer & Comments

Answer: 2- Cystinuria

Cystinuria is a disorder of proximal tubular
cells. Amino aciduria (COAL - cystine,
ornithine, arginine, lysine) - causes cystine
stones (accounts for 1% of all stones).
Urinalysis may show typical hexagonal or
benzene crystals, which are essentially
pathognomonic of cystinuria. Cystine stones
are pale yellow.

Renal calculi from a patient with cystinuria
who had nephrectomy First-line therapy in
most cases is a conservative approach,
including large-volume fluid intake, regular
urine pH monitoring (urine pH level of 7.5 and
<8), dietary restrictions, and urinary
alkalization with potassium citrate.

[ Q: 501 ] MRCPass - Nephrology

A 45 year woman has a renal
transplantation. She has a history of diabetes.
4 months after transplantation she presents
acute pain in region of transplanted kidney.

Urinalysis shows nitrites +, protein +, no blood
or leucocytes.

Which one of following is the likely diagnosis?

1- Nephrolithiasis

2- Pyelonephritis

3- Graft rejection

4- Diabetic nephropathy

5- Native polycystic kidneys

Answer & Comments

Answer: 2- Pyelonephritis

The patient has immunosuppression following
transplantation. Graft rejection is possible, but
the history would be most consistent with a
pyelonephritis because of positive nitrites and
loin pain.

[ Q: 502 ] MRCPass - Nephrology

A 50 year old woman has a corrected
calcium of 2.90 mmol/I and phosphate 0.7
mmol/l, parathyroid hormone (PTH) level is
10.0 pmol/l (1.1 to 6.8), and the 24-hour
urinary calcium excretion is 0.8 mmol/l.

Plasma creatinine is 120 micromol/l and
alkaline phosphatase 130U/I. There is a family
history of hypercalcaemia.

Which of the following is likely?

1- The diagnosis is likely to be primary
hyperparathyroidism

2- Treatment with oral phosphate
supplements should suppress her PTH level

3- She should be screened for a mutation in
the multiple endocrine neoplasia -1 gene.

4- She has an abnormality in the calcium¬
sensing receptor

5- Parathyroid surgery will be necessary in the
future

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Answer & Comments

Answer: 4- She has an abnormality in the
calcium-sensing receptor

The patient has an inappropriately high level
of PTH, but the reduced urine calcium
excretion suggests that she has familial
hypocalcuric hypercalcaemia (FHH) due to a
mutation in the calcium receptor. Familial
hypocalciuric hypercalcemia (FHH) or familial
benign hypercalcemia is an autosomal
dominant inherited disorder of calcium
metabolism. It is characterized by lifelong
asymptomatic hypercalcemia associated with
a relative hypocalciuria and a tendency to
hypermagnesemia. The biochemical features
of this disorder are difficult to distinguish from
mild primary hyperparathyroidism. Several
patients have had parathyroidectomy for
hyperparathyroidism with no effect on
calcium levels.

stenosis or outflow obstruction, hence a renal
biopsy is the best way to confirm a diagnosis.

[ Q: 504 ] MRCPass - Nephrology

A 45 year old woman presents with
acute pain that radiates from his left loin to
his left groin. The pain comes for a few
seconds, and then goes. It is sharp in nature. A
plain abdominal X Ray is unremarkable.
Ultrasound examination demonstrates pelvi-
calyceal dilatation and the presence of several
masses.

The most likely diagnosis is:

1- Papillary necrosis

2- Recurrent UTIs

3- Cystine renal stones

4- Uric acid renal stones

5- Renal cell carcinoma

[ Q: 503 ] MRCPass - Nephrology

Answer & Comments

•i J

A 60 year old man has a history of

Answer: 4- Uric acid renal stones

hypertension. His blood show : urea 20 pmo
& creatinine 320 pmol/l.

Urinalysis showed blood ++ protein ++. Renal
ultrasound showed left kidney : 9 cm long,
right be 8.5 cm long and no evidence of
hydronephrosis.

What is the next best investigation?

1- Renal biopsy

2- DMSA renography

3- Intravenous urography

Urinary stones made of calcium oxalate or of
cystine are radio-opaque and would be visible
on a plain X-ray. In contrast, uric acid stones
are radiolucent, hence most likely in this case.

[ Q: 505 ] MRCPass - Nephrology

A 23-year-old man presents with a
rash on his legs. He had a chest infection last
week, and now has symptoms of joint pains.
Stick testing of his urine reveals proteinuria
and haematuria +++.

4- Magnetic resonance angiography

5- Retrograde pyelography

Answer & Comments

Answer: 1- Renal biopsy

There is proteinuria and haematuria. Renal
impairment is likely to be related to
glomerular pathology rather than renal artery

What is the most likely diagnosis?

1- IgA nephropathy

2- Mixed essential cryoglobulinaemia

3- Membranous glomerulonephritis

4- Acute nephritic syndrome

5- Henoch Schonlein purpura

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Answer & Comments

Answer: 5- Henoch Schonlein purpura

Henoch-Schonlein purpura is a disease that
has the symptoms of purple spots on the skin,
joint pain, gastrointestinal symptoms, and
glomerulonephritis. The exact cause for this
disorder is unknown. The syndrome is usually
seen in children, but people of any age may be
affected. It is more common in boys than in
girls.

Many people with Henoch-Schonlein purpura
had an upper respiratory illness in the
previous weeks. In this case, if a rash were not
present, then IgA nephropathy would the
most probable cause of his urinary findings.

Mixed essential cryoglobulinaemia will often
present with palpable purpura on the legs and
nephritis, but is an uncommon disease of
older patients.

[ Q: 506 ] MRCPass - Nephrology

A 60 year old man presents with pain
in the lower back. The pain begins in the lower
back and radiating to the lower abdomen. He
has not been on any medications recently.
Investigations reveal a normocytic
normochromic anaemia, raised erythrocyte
sedimentation rate and C-reactive protein.
Renal function is impaired. Ultrasound scan
shows bilateral hydronephrosis.

Which of the following investigations should
be done?

1- CT abdomen

2- 24 hour urine for creatinine clearance

3- 24 hour urine protein

4- Intravenous urogram

5- MAG 3 scan

The diagnosis is idiopathic retroperitoneal
fibrosis. CT scanning will show a peri-aortic
fibrotic, which can be confirmed by CT guided
biopsy.

[ Q: 507 ] MRCPass - Nephrology

A 20-year-old man presented to a
clinic with a tw o-day history of pain in his
knees and shoulders. The pain had become
severe enough that he was unable to walk.
The patient also noted a low -grade fever and
a purplish rash on his shins and feet on the
morning of admission.

Examination of the extremities revealed
bilaterally tender, sw ollen wrists, knees and
ankles without effusion or erythema. The
patient had diffuse tenderness in several
muscle groups, including the quadriceps,
latissimus dorsi and trapezius. Skin
examination revealed a palpable purpuric rash
on both ankles that tapered up to the knees.

Investigations showed renal impairment and
also haematuria.

Which one of the following is most likely?

1- Henoch Schonlein purpura

2- Infective endocarditis

3- Cyclosporin toxicity

4- Rhabdomyolysis

5- Diabetic glomerulosclerosis

Answer & Comments

Answer: 1- Henoch Schonlein purpura

Henoch Schonlein purpura (HSP) causes a rash
around the trunk and polyarthritis. It is
associated with renal failure caused by a
glomerulonephritis which is similar to Ig A
glomerulonephritis causing macroscopic
haematuria.

Answer & Comments

Answer: 1- CT abdomen

Apart from a rash, arthralgia and arthritis are
the most common manifestations of Henoch-
Schonlein purpura, occurring in 80 to 90
percent of cases. Joint involvement is usually

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oligoarticular and primarily affects the large
joints of the shoulders, knees, wrists and
elbows. The image below shows the rash of
HSP.

[ Q: 508 ] MRCPass - Nephrology

An 25 year old man is referred to the
outpatient clinic following the finding that he
of microscopic haematuria and proteinuria on
the urine dipstick. He also has bilateral
sensorineural deafness. His sister also has
deafness.

What is the likely diagnosis?

1- Liddle's syndrome

2- Bartter's syndrome

3- Alport's syndrome

4- Von Hippel Lindau syndrome

5- Holt Oram syndrome

Answer & Comments

Answer: 3- Alport's syndrome

Inheritance can be X-linked dominant,
autosomal dominant and, rarely, autosomal
recessive in Alport's syndrome. It is a
hereditary disease of basement membranes
which is characterised by sensorineural
deafness and renal failure.

Patient's with Alport's syndrome often present
with haematuria and proteinuria. Rarely
cataracts also occur.

Management include monitoring of renal
function (until the need for dialysis) and
management of hypertension.

[ Q: 509 ] MRCPass - Nephrology

A 50 year old lady has a diagnosis of
scleroderma. She is admitted with dizziness.
On examination, her pressure is 220/110 and
there is bilateral papilloedema. Blood tests
reveal a creatinine of 180 micromol/l.

What is the best medication for treatment?

1- Amlodipine

2- Sodium nitroprusside

3- Lisinopril

4- Propafenone

5- Labetalol

Answer & Comments

Answer: 3- Lisinopril

The term "scleroderma renal crisis" has been
used to characterize kidney involvement in
scleroderma, because of the abrupt and
potentially devastating consequences of
kidney disease.

When any persistent rise in blood pressure is
detected, or if there is the appearance of
proteinuria, treatment should promptly be
instituted with angiotensin converting enzyme
(ACE) inhibitors (enalapril, lisinopril etc).

Angiotensin-converting enzyme (ACE)
inhibition has significantly improved survival in
such patients.

[ Q: 510 ] MRCPass - Nephrology

A 65 year old man was found on the
floor in a flat and brought into hospital by
ambulance. He has a temperature of 35°C, and
a blood pressure of 110/70 mmHg. Dipstick
urine analysis shows : blood +++.

Blood test show :

Creatinine, 280 micromol/L, LDH 900 U/L.

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What likely cause of renal failure?

1- Diabetes

2- Acute tubular necrosis

3- Rhabdomyolysis

4- Vasculitis

5- Hypertension

Answer & Comments

Answer: 3- Rhabdomyolysis

A patient who has been on the floor some
time may have muscle injury and consequent
rhabdomyolysis. There would be urine
myoglobin and a CK measurement may be in
the thousands.

[ Q: 511 ] MRCPass - Nephrology

A 75 year old gentleman referred for
back and leg pains. He was unable to mobilise
unaided and complains of urinary
incontinence. He has had a TURP in the past
for benign prostatic hypertrophy.

On examination, he has 3/5 power in his left
leg and 2/5 in his right, His plantars are
upgoing. Rectal examination reveals an
enlarged, irregular prostate and lax anal tone.
There is sensory deficit over both the lower
limbs upto the suprapubic level.

There is a palpable bladder.

Investigations show :
Na 138 mmol/l

K 4.5 mmol/l
Urea 4.8 mmol/l
Creatinine 100 mmol/l

Glucose 13 mmol/l

PSA 910

He is commenced on high dose steroids.
However, he appears to be deteriorating
neurologically.

What is the definitive treatment?

1- Orchidectomy

2- Further high dose dexamethasone

3- Stilboestrol and aspirin

4- Goserelin

5- Bicatulamide

Answer & Comments

Answer: 1- Orchidectomy

This man presents with spinal cord
compression, which is potentially reversible.
Out of the options, orchidectomy is the
correct treatment, as this will eliminate all
androgens immediately, which is the cause of
the tumour growth. Bicalutamide, which is an
androgen receptor antagonist, is slow acting
and will not have an early effect. Goserelin is
contraindicated in patients with acute spinal
cord compression, as it will cause "tumour
flare" and may worsen. It is usually prescribed
5-7 days post bicalutamide loading in order to
avoid the flare.

[ Q: 512 ] MRCPass - Nephrology

A 30 year old man has blood
pressure of 200/90. His serum potassium is
2.8 mmol/l, creatinine is 90 pmol/l. Urine
dipstick shows protein trace.

Which of the following diagnosis is likely?

1- Conn's syndrome

2- Phaeochromocytoma

3- Diabetic nephropathy

4- Hypertensive nephropathy

5- Renal artery stenosis

Answer & Comments

Answer: 1- Conn's syndrome

High levels of aldosterone in Conn's (primary
aldosteronism) can also cause sodium
retention, potassium loss and hypertension.

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[ Q: 513 ] MRCPass - Nephrology

A 15 year old girl has nephrotic
syndrome due to minimal change
glomerulonephritis.

What is the likely long term outcome?

1- Long term remission

2- Recurrent relapses

3- Chronic renal impairment

4- Persistent proteinuria

5- Persistent hypercholesterolaemia but not
proteinuria

Answer & Comments

Answer: 1- Long term remission

Minimal change disease usually responds well
to medical treatment, with response to
corticosteroids usually within the first month.
90% of patients with minimal change disease
in the younger age group achieve remission
after 8 weeks of steroids.

[ Q: 514 ] MRCPass - Nephrology

A 45 year old man had recurrent
flank pains and was found to have renal calculi
on the ultrasound scan. His serum calcium
measurements were normal. A 24 hour urine
analysis revealed:

calcium 12.2 mmol/24 hours (2.5 - 7.5)

oxalate 320 mmol/24 hours (90 - 450)

uric acid 3 mmol/24 hours (1.5 - 4.5)

citrate 2.1 mmol/24hours(0.3-3.5)

What is the recommended therapy to reduce
stone formation?

1- Prednisolone

Answer & Comments

Answer: 2- Calcium restriction

The patient has hypercalciuria causing calculi
formation. The first step should be to reduce
calcium intake. The second could be to use
thiazide diuretics.

[ Q: 515 ] MRCPass - Nephrology

A haemodialysis patient with
hypertensive nephropathy, has the following
blood results: calcium 2.85 (2.25-2.7) mmol/l,
phosphate 2.3 (0.8-8)mmol/l. PTH is 1.2 (0.8-8
pmol/l). The patient's medication includes
alfacalcidol each day and calcium acetate as a
phosphate binder before each meal.

Which of the following should be
recommended?

1- The patient should have a low calcium diet

2- Increased frequency of haemodialysis

3- Dialysate calcium should be lowered

4- Phosphate restriction in the diet

5- Calcium acetate dose should be reduced

Answer & Comments

Answer: 4- Phosphate restriction in the diet

Low ering the phosphate (rather than the
calcium) is the most important measure, as
the elevated phosphate stimulates
parathyroid proliferation and PTH secretion.
This is best done by reinforcing dietary
restriction and ensuring that the patient is
recieving adequate dialysis. The vitamin D
analogue w ill be increasing absorption of
calcium and phosphate so this should be
reduced or stopped.

2- Calcium restriction

3- Penicillamine

4- Increase alcohol consumption

5- Bendrofluazide

[ Q: 516 ] MRCPass - Nephrology

In a patient with renal failure, use of
which of the following medications would
suggest a possible diagnosis of retroperitoneal
fibrosis ?

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1- Bendrofluazide

2- Methysergide

3- Diltiazem

4- Aspirin

5- Clopidogrel

Answer & Comments

Answer: 2- Methysergide

Drugs associated with retroperitoneal fibrosis
include:

methysergide

5- Metronidazole

Answer & Comments

Answer: 2- Vancomycin

Peritonitis is characterized by abdominal pain
and cloudy bags with greater than 100 WBC
per ml of fluid. Typically when more than one
organism is present, the diagnosis becomes
more likely. Treatment is usually with a first
generation cephalosporin, along with
gentamicin (then adjusted according to
culture sensitivities) or vancomycin with
tobramicin.

beta-adrenergic blockers

lysergic acid diethylamide

methyldopa

amphetamines

phenacetin

pergolide

cocaine

[ Q: 517 ] MRCPass - Nephrology

A 36 year old male patient was
admitted with abdominal pain, diarrhea,
nausea, vomiting and fever which had started
one week before.

The patient had been followed up with
predialysis Chronic Renal Failure(CRF)
diagnosis for 4 years and has been receiving
continuous ambulatory peritoneal dialysis
(CAPD) treatment for 4 months.

In the peritoneal fluid, 1600/ mm 3 cells were
detected and 70% of them were
polymorphonuclear leukocytosis.

Whot should the patient be treated with?

1- Amoxycillin

2- Vancomycin

3- Ciprofloxacin

4- Trimethoprim

[ Q: 518 ] MRCPass - Nephrology

A 45 year old man presents to to the
hospital with severe lethargy. Initial
investigations identify a significant anaemia
with fragmentation on the blood film and low
platelets. Clotting screen is normal. His U+Es
show a creatinine of 260 umol/l. BP was
recorded at 180/100.

What is the most likely diagnosis?

1- Thrombotic thrombocytopenic purpura
(TTP)

2- Disseminated intravascular coagulation

3- Haemolytic uraemic syndrome

4- Hypertensive nephropathy

5- Polyarteritis nodosa

Answer & Comments

Answer: 3- Haemolytic uraemic syndrome

HUS is a disorder characterised by
thrombocytopenia, microangiopathic

haemololytic anaemia (anaemia secondary to
red blood cell fragmentation) and renal
(kidney) failure. About 90 per cent of HUS
cases are caused by a certain group of bacteria
know n as verocytotoxin-producing E.coli
(VTEC). The most commonly associated strain
is E.coli 0157:H7. Sporadic cases of haemolytic
uraemic syndrome (not associated with

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diarrhoea) can be seen with HIV, malignancy,
SLE. Treatment of sporadic HUS is with plasma
exchange and fresh frozen plasma.

[ Q: 519 ] MRCPass - Nephrology

A haemodialysis patient has
recurrent knee and ankle sw elling and pains.
Aspiration of the knee synovial fluid reveals
negatively birefringent crystals.

Which one of the following treatments is the
least effective either acutely or in the chronic
situation?

1- Probenecid

2- Prednisolone

3- Increased dialysis

4- Allopurinol

5- Colchicine

Answer & Comments

Answer: 1- Probenecid

Negative birefringence with polarised light
demonstrates urate crystals, making the
diagnosis consistent with gout. Probenecid is a
uricosuric agent (reduces the reabsorption of
uric acid), hence likely to produce little benefit
in a patient who has significant renal
impairment.

Allopurinol (xanthine oxidase inhibitor) will
reduce urate production, prednisolone or
colchicine have anti-inflammatory properties.

Haemodialysis will also increase urate
clearance.

Intracellular monosodium urate crystal viewed
under a polarized light microscope (right) and
a conventional light microscope (left).

[ Q: 520 ] MRCPass - Nephrology

#1 -

* A 45 year old patient with chronic

hepatitis C has a creatinine of 140 pmol/l. His
BP is 150/90. He has urine dipstick showing
blood ++, protein +++.

Which of the following might be demonstrated
on the histology?

1- Minimal change glomerulonephritis

2- Membranous glomerulonephritis

3- Focal segmental glomerulonephritis

4- Membranoproliferative glomerulonephritis

5- Glomerulosclerosis

Answer & Comments

Answer: 4- Membranoproliferative

glomerulonephritis

This is chronic hepatitis C infection. It is
associated with cryoglobulinaemia (which may
present as a vasculitic rash) and
membranoproliferative glomerulonephritis.

Also, it (less commonly) can cause
membranous glomerulonephritis.

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The glomerulus has increased overall
cellularity and increased mesangial cellularity
in membranoproliferative glomerulonephritis.

Mesangial proliferation may represent a
subset of patients who respond poorly to
steroids.

^ [ Q: 522 ] MRCPass - Nephrology

# A 22 year old lady has a 5 year
history of loin pains. She noticed recently that
she had passed a small stone when passing
urine. A 24 hour urine collection showed
normal calcium and phosphate levels. Urinary
levels of arginine, cystine, lysine and ornithine
were elevated.

[ Q: 521 ] MRCPass - Nephrology

A 34 year old patient has 4g of
proteinuria over 24 hours. She is treated with
corticosteroids.

Which of the following predicts a good
response to corticosteroid therapy in nephrotic
syndrome?

1- Hypertension

2- Haematuria

3- Proteinuria

4- The onset is within the first month of life

Which of the following is true?

1- Renal failure does not occur

2- The stone is radiolucent

3- There is accumulation of cystine in
epithelial cells

4- There is tubular necrosis

5- The condition is autosomal dominant

Answer & Comments

Answer: 3- There is accumulation of cystine in
epithelial cells

5- Proliferative changes are observed on renal
biopsy

Answer & Comments

Answer: 3- Proteinuria

Proteinuria is highly selective, occuring in 75%
of patients with minimal change, which is
responsive to steroids.

There is poor response to steroids in
membranous, membranoproliferative, focal
segmental glomerulonephritis.

Hypertension is aggravated by steroids.
Haematuria indicates that more sinister
causes such as streptococcal infection may
have occurred. Early onset nephrotic
syndrome is correlated with severity, peak
onset age is 2-4 yrs.

Cystinuria is an autosomal recessive defect in
reabsorptive transport of cystine and the
dibasic amino acids ornithine, arginine, and
lysine from the luminal fluid of the renal
proximal tubule and small intestine. The
genetic defect impairs intestinal absorption
and renal reabsorption of cystine, causing
elevated urinary levels of cystine and
subsequent crystallization and stone
formation. The only phenotypic manifestation
of cystinuria is cystine urolithiasis. Cystinuric
patients usually present with renal colic.

Uncommon presentations include hematuria,
chronic backache, and urinary tract infection.
Twenty-five percent of symptomatic patients
report their first stone in the first decade of
life.

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[ Q: 523 ] MRCPass - Nephrology

A 50 year old man attends casualty
concerned that on passing urine he also
passed a small lump. He has a history of
arthritis, diabetes and hypertension. His
serum creatinine is 180 micromol/l and his
albumin is 38 g/l. A frozen section is
performed by a pathologist who reports that
the lump is a renal papilla.

What is the diagnosis related to?

1- Diabetic nephropathy

2- Membranous nephropathy

3- Minimal change nephropathy

4- NSAID nephropathy

5- Hypertensive nephropathy

Answer & Comments

Answer: 4- NSAID nephropathy

This is a case of papillary necrosis due to
analgesic nephropathy. This is due to chronic
vasoconstriction of blood vessels within the
kidney (prostaglandin reduction by NSAIDs).

Renal papillary necrosis (RPN) is the necrosis
of the renal medullary pyramids and papillae
brought on by a host of associated conditions
and toxins.A useful mnemonic device for the
conditions associated with RPN is POSTCARDS,
which stands for the following:

[ Q: 524 ] MRCPass - Nephrology

A 35 year old man presents with a
history of recurrent episodes of haematuria.
This is worse during episodes of upper
respiratory infections and comes on within
approximately 12-24 hours of development of
pharyngitis. He also describes haematuria.
Clinically he looks well, there is no oedema,
blood pressure is 120/70 and creatinine is 100
pmol.

The renal biopsy is likely to show:

1- Proliferative glomerulonephritis with
crescent formation

2- Mesangial proliferation

3- Minimal change

4- Podocyte proliferation

5- Basement membrane destruction

Answer & Comments

Answer: 2- Mesangial proliferation

The description of recurrent haematuria
related to pharyngitis in a young male with no
physical signs points tow ards IgA
nephropathy (Berger's disease). The light
microscopic feature of this is mesangial
proliferation. Immunofluorescence would
demonstrate IgA deposition in the mesangium
as confluent masses or discrete granules.

Pyelonephritis
Obstruction of urinary tract
Sickle cell
Tuberculosis
Cirrhosis of the liver
Analgesic abuse
Renal transplant rejection
Diabetes mellitus
Systemic vasculitis

[ Q: 525 ] MRCPass - Nephrology

A 25 year old drug user, presented to
hospital unwell. He has a past medical history
of type 1 diabetes. He had injected cocaine
into his leg a day ago. On examination, he was
pale, BP was 70/40 mmHg, Temperature was

36°C. He complained of a painful, sw ollen,
right leg.

Investigations showed:
sodium 136 mmol/l

potassium 5.9 mmol/l
urea 15 mmol/l

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creatinine 190 pmol/l
Creatine Kinase 12,000 (24-170) U/l
Urine dipstick showed myoglobinuria.
What is the diagnosis?

1- Rhabdomyolysis

2- Hypocalcaemic hypocalciuria

3- Rapidly progressive glomerulonephritis

4- Diabetic nephropathy

5- Endocarditis

Answer & Comments

Answer: 1- Rhabdomyolysis

Rhabdomyolysis results from muscle injury
and the release of myoglobin, which is toxic to
the renal tubules. Myoglobinuria usually
occurs. Muscle cells also release creatinine
kinase and potassium when they are injured.

[ Q: 526 ] MRCPass - Nephrology

Which of the following options do
you think would be the most appropriate in
supporting a diagnosis of reflux nephropathy
in a 35 year old woman with plasma creatinine
330 micromole/litre and a history of repeated
urinary tract infections?

1- Intravenous urography

2- CT of abdomen

[ Q: 527 ] MRCPass - Nephrology

A 75 year old diabetic man
presented to his local hospital with unstable
angina where he received conventional
treatment with intravenous nitrates and
heparin. His pain subsided but he
subsequently developed recurrent episodes of
"flash" pulmonary oedema and recalcitrant
hypertension. These were accompanied by an
decline in renal function over four weeks until
eventually he became dependent on dialysis.

Severe hypertension and signs of peripheral
vascular disease were found on physical
examination, but there w ere no audible renal
bruits. Non-blanching purpuric lesions
suggestive of embolisation were noted on his
toes.

Blood tests showed a marked peripheral blood
eosinophilia of 0.59 x 10 9 /L (< 0.40) and a C3
complement component just below the lower
limit of normal, at 0.59 g/l (0.6-1.6). An
angiogram performed using spiral computed
tomography showed an atheromatous aorta
but no evidence of renal artery stenosis. A
percutaneous renal biopsy showed clefts in
the lumen of intrarenal arterioles.

What is the diagnosis?

1- Diabetic nephropathy

2- Minimal change glomerulonephritis

3- Endocarditis

3- MRI of abdomen

4- Cholesterol embolisation

4- Isotopic imaging with 99mTc-DTPA.

5- Renal ultrasound

Answer & Comments

Answer: 5- Renal ultrasound

Ultrasound is a good method of detecting
renal scars. DMSA, which is taken up by
tubular cells can be used to detect scars (as
opposed to DTPA which is filtered by the
glomerulus and not taken up by tubular cells,
hence not good for detecting scarring).

5- Lupus nephritis

Answer & Comments

Answer: 4- Cholesterol embolisation

Cholesterol embolisation characterised by a
classic triad of livedo reticularis acute renal
failure, and eosinophilia. Occasionally the
presentation is atypical, with fever, myalgia,
and multiorgan involvement mimicking
systemic vasculitis. CRP and ESR are typically
elevated. Risk factors for cholesterol

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embolism include hypertension, diabetes, and
aortic aneurysm.

[ Q: 528 ] MRCPass - Nephrology

A 35 year old patient has proteinuria
and suspected renal disease.

In which one of the situations would
corticosteroids be useful in treatment?

1- Renal vein thrombosis

2- Minimal change disease

3- Scleroderma

4- Membranous nephropathy

5- Amyloidosis

Answer & Comments

Answer: 2- Minimal change disease

Out of all the options, minimal change disease
is the most well known to be steroid
responsive, with a good prognosis.

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^ [ Q: 529 ] MRCPass - Neurology

f | -

# A 55 year old man patient presents
with an 8 month history of progressive
difficulty in swallowing, and dysarthria. He has
lost 6 kg in weight. On examination he has a
fasciculation on the tongue and a brisk jaw
jerk.

What is the likely diagnosis?

Answer & Comments

Answer: 4- Glioblastoma

The rapid onset of symptoms make it likely
that this is a malignant lesion, and the most
common malignancy of the central nervous
system is a glioma. Glioblastoma multiforme is
by far the most common and most malignant
of the glial tumors.

1- Amyotrophic lateral sclerosis

2- Subacute combined degeneration of the
cord

3- Senile dementia

4- Multiple sclerosis

5- Guillain Barre syndrome

Answer & Comments

Answer: 1- Amyotrophic lateral sclerosis

A fifth of patients with amyotrophic lateral
sclerosis have bulbar involvement. This is a
classic presentation of a patient with this
variant of motor neuron disease.

[ Q: 530 ] MRCPass - Neurology

A 60 year old man is brought has had
6 seizures over the past week. The seizures
are generalised tonic clonic.

He has complained of a severe headache, and
examination shows increased tone on the left
with mild hemiparesis. There is papillodoema
in both eyes. An emergency MRI scan shows a
mass in the right cerebral hemisphere.

What is the most likely diagnosis?

Glioblastoma

[ Q: 531 ] MRCPass - Neurology

A 42 year old man has weakness in
the extensors of the upper limb and flexors of
the lower limb muscles. His speech has a nasal
quality. There is tongue fasciculation.

What is the likely diagnosis?

1- Wilson's disease

2- Creutzfeldt Jakob disease

3- Motor neuron disease

4- Myasthenia gravis

5- Thyrotoxicosis

1- Medulloblastoma

2- Craniopharyngioma

Answer & Comments

Answer: 3- Motor neuron disease

3- Meningioma

4- Glioblastoma

5- Astrocytoma

In motor neuron disease, UMN signs include
muscle spasticity, slowed recruitment of
voluntary muscle strength, weakness
especially in the extensors of the upper limb
and flexors of the lower limb muscles,
pseudobulbar palsy.

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LMN features include muscle wasting and
fasciculation, depressed reflexes and bulbar
palsy. Onset of the disease is usually in mid to
late adult life with the incidence increasing
with advancing age.

[ Q: 532 ] MRCPass - Neurology

Following a football injury, a man
has developed foot drop and has lost
sensation to the dorsal part of the foot.

Which nerve is most likely to have been
involved?

1- Tibial

2- Sciatic

3- Common peroneal

4- Femoral

5- Gluteal

Answer & Comments

Answer: 3- Common peroneal

The common peroneal nerve controls foot
eversion and dorsiflexion. Sensation is
supplied to the antero-lateral part of the leg
and the dorsum of the foot.

Coir iv on
Peroneal

Bi anch to
Peroneal

• ever ter)
iruscles

Knee

Cap

Bianch to
oorsiflexors

" [ Q: 533 ] MRCPass - Neurology

t -

A 70 year old woman with a history
of hypertension and insulin-dependent
diabetes mellitus presented with new onset of
uncontrolled violent movements of the left
extremities accompanied by headaches.

Neurological examination was normal except
for the constant, relentless, violent movement
of her left arm and leg. Although she was fully
awake, alert, and oriented, she could not stop
the abnormal movements except for a short
period of time.

This presentation is likely to be due to a lesion
in the:

1- Substantia nigra

2- Globus pallidus

3- Putamen

4- Hypothalamus

5- Subthalamic nucleus

Answer & Comments

Answer: 5- Subthalamic nucleus

Hemiballismus is a rare disorder characterised
by involuntary wild flinging movements of the
limbs. It is usually unilateral (hence
hemiballismus) and is caused by lesions in the
contralateral subthalamic nucleus.

VL nucleus at
thalamus

Substantia

nigra

Globus

paflidus

Subthalamic

nucleus

Basal ganglia
and associated

structures

Caudate
nucleus

Striatum

Putamen

[ Q: 534 ] MRCPass - Neurology
A 20 year old lady presents with a

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history of a single tonic-clonic seizure. She had
not been taking any illicit drugs. She also
reports the occurrence of occasional absent
spells and brief jerking of his upper limbs,
when she has been out late partying.

Which of the Following drugs is most
appropriate?

1- Lorazepam

2- Carbamazepine

3- Phenytoin

4- Gabapentin

5- Sodium valproate

Answer & Comments

Answer: 5- Sodium valproate

This patient is likely to have juvenile myoclonic
epilepsy (JME), and valproate is the treatment
of choice. Juvenile myoclonic epilepsy (JME) is
an idiopathic generalized epileptic syndrome
characterized by myoclonic jerks, generalized
tonic-clonic seizures (GTCSs), and sometimes
absence seizures.

These can be precipitated when the patient is
sleep deprived. Apart from sodium valproate,
lamotrigine and topirimate can also be used.

[ Q: 535 ] MRCPass - Neurology

A 30 year old patient has recurrent
episodes of severe, unilateral, pain felt in the
region of the eye and forehead associated
with lacrimation.

The most likely diagnosis is:

1- Migraine

2- Subarachnoid haemorrhage

3- Retro-orbital tumour

4- Cluster headache

5- Migranous neuralgia

Cluster headache causes severe, usually
unilateral, pain felt in the region of the eye
and forehead associated with lacrimation,
conjunctival injection and occasionally
transient Horner's syndrome.

Oxygen and triptans may arrest attacks,
prophylaxis with propranolol, pizotifen, and
especially verapamil may prevent further
episodes.

[ Q: 536 ] MRCPass - Neurology

A 70 year old man has a 2 month
history of progressive weakness in his legs. He
has weakness in the hip and knee distribution.
Knee and ankle reflexes are brisk. Plantars are
upgoing bilaterally. He has sensory loss from
legs upwards towards the T5 level.

Which one of the Following is a likely
diagnosis?

1- Subacute combined generation of cord

2- Friedrich's ataxia

3- Meningioma

4- Hereditary spastic paraparesis

5- Tropical spastic paraparesis

Answer & Comments

Answer: 3- Meningioma

A meningioma involving high in the spinal cord
(thoracic region) can cause a T5 level. The rest
are all causes of spastic paraparesis but are
unlikely to cause a sensory level on clinical
examination.

Answer & Comments

Answer: 4- Cluster headache

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Spinal Cord Meningioma

[ Q: 538 ] MRCPass - Neurology

A 45 year old man has presented
with lower back pain, radiating to his buttocks,
associated with lower limb parathesia over
the last few days. He is unable to walk due to
leg weakness. The ankle reflexes are absent.

Whot is the diagnosis?

1- Disc prolapse

2- Transverse myelitis

3- Guillain Barre syndrome

4- Multiple sclerosis

5- Friedrich's ataxia

[ Q: 537 ] MRCPass - Neurology

A 50 patient is assessed for gradually
progressive dementia over several months.
Whilst he was on the ward he was noticed to
have myoclonic jerks of his hands.

Whot is the likely couse?

1- HIV encephalopathy

2- Parkinson's disease

Answer & Comments

Answer: 3- Guillain Barre syndrome

Guillain Barre syndrome is preceded by
respiratory or gastrointestinal symptoms in
two-thirds, but not all, cases. Lower back pain,
often radiating to the buttocks occurs in a
third of cases. Difficulty walking in this case is
due to distal weakness and absent distal
reflexes suggest GBS.

3- Alzheimer's disease

4- Pick's disease

5- Creutzfeldt Jakob disease

Answer & Comments

Answer: 5- Creutzfeldt Jakob disease

Creutzfeldt Jakob disease (CJD) usually occurs
in the 45-75 year age group and most
commonly presents as a rapidly evolving
multifocal dementia with myoclonic jerks in
the latter stages. New variant CJD, which has
been strongly linked to infection from meat
products of cows with BSE, tends to present
with behavioural and psychiatric disturbances
progressing to inco-ordination and dementia
with myoclonic jerks.

[ Q: 539 ] MRCPass - Neurology

A 62 year old man presents with a
resting tremor of his right arm. He was found
to have cogwheeling and bradykinesia. His gait
is shuffling in nature.

Which one of the Following drugs is most likely
to help her tremor?

1- Amantadine

2- Benzhexol

3- Bromocriptine

4- Co-Careldopa

5- Selegiline

Answer & Comments

Answer: 2- Benzhexol

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Benzhexol is an anticholinergic drug (used to
alleviate tremors in parkinson's disease). The
first line treatment is with L-dopa which is the
metabolic precursor of L-dopa. Benzhexol is
not effective against bradykinesia.

[ Q: 540 ] MRCPass - Neurology

A 46 year old female had a traumatic
left sided tooth extraction 6 years ago. Since
then she is complaining of facial pain mainly
over upper part of left face with intermittent
exacerbation. Occasionally the pain radiates to
right side of the face.

What is the likely diagnosis?

1- Atypical facial pain

2- Trigeminal neuralgia

3- Dry socket cyst

4- Bell's palsy

5- Periodontitis

Answer & Comments

Answer: 1- Atypical facial pain

Complicated dental procedures or other forms
of trauma can lead to a form of atypical facial
pains which is also known as post traumatic
facial pain/ neuralgia. The pain is usually self
limiting after several years.

[ Q: 541 ] MRCPass - Neurology

A 25 year old secretary has had
several episodes of brief jerking of the right
arm over the past few weeks.

There is no loss of consciousness. A CT scan of
the head is unremarkable.

Which is the best medication to commence?

1- Carbamazepine

2- Phenytoin

3- Lorazepam

4- Diazepam

5- Levodopa

Answer & Comments

Answer: 1- Carbamazepine

Brief episodes of jerking suggests simple
partial seizures. Carbamazepine is first line
therapy for this.

[ Q: 542 ] MRCPass - Neurology

A 63 year old man who has been
diagnosed with a glioma is commenced on
chemotherapy. 4 days later, he begins to
behave strangely, and has suicidal ideation.

Which one of the Following is most likely?

1- Vincristine encephalitis

2- Hyponatraemia

3- Steroid psychosis

4- Hypoglycaemia

5- Hypocalcaemia

Answer & Comments

Answer: 3- Steroid psychosis

Incidence of steroid associated cognitive
changes including psychosis are high
particularly when high dose steroids are used
(e.g. dexamethaxone).

[ Q: 543 ] MRCPass - Neurology

A 75 year old man was admitted to
the hospital after being unable to cope. His
neighbours say that he had been increasingly
confused over the last month and two weeks
ago was seen to have a generalised seizure.
He had no neurological signs on examination
apart from an upgoing plantar on the left.

Which of the Following is most likely?

1- Subarachnoid haemorrhage

2- Meningitis

3- Subdural haematoma

4- Parkinson's syndrome

5- Meningioma

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Answer & Comments

Answer: 3- Subdural haematoma

A history of confusion along with a possible
seizure/fall in the elderlly should alert towards
subdural haematoma.

Subdural Haematoma

[ Q: 544 ] MRCPass - Neurology

A 65 year old man has a history of
hypertension. He presents with sudden onset
dysarthria, vomiting hiccup and vertigo.

On examination, he has a right sided Horner's
syndrome, right-sided cerebellar ataxia, loss of
pain and temperature sensation on the right
hand side of the face, and loss of pain and
temperature sensation in the left upper and
lower limbs.

What is the likely diagnosis?

1- Cerebellar infarct

2- Inferior parietal infarct

3- Superior temporal infarct

4- Subthalamic nucleus infarct

5- Lateral medullary infarct

Answer & Comments

Answer: 5- Lateral medullary infarct

In the lateral medullary syndrome (inferior
cerebellar artery involvement), 9th and 10th
nerve involvelement leads to dysphagia and

dysarthria. There is also ipsilateral Horner's
syndrome and facial sensory loss, and
contralateral pain/ temperature sensory loss
to upper and lower limbs.

[ Q: 545 ] MRCPass - Neurology

A 60 year old man presents with
drowsiness and confusion. A friend says he
has been confabulating about having his
wallet stolen. On examination, he is unkempt,
his pupil reflexes are normal and eye
movements are normal. There were otherwise
no focal neurological deficits. A CT scan of the
brain showed mild cerebral atrophy. He has a
MCV of 105 fl.

Which diagnosis is most likely?

1- Transient global amnesia

2- Korsakoff's psychosis

3- Wernicke's encephalopathy

4- Alzheimer's

5- Pick's disease

Answer & Comments

Answer: 2- Korsakoff's psychosis

The high MCV suggests heavy alcohol drinking.
He is delusional (having his wallet stolen) and
also there are no signs of nystagmus or
cerebellar signs to support Wernicke's
encephalopathy.

Short term memory loss, amnesia and
personality changes are also seen in
Korsakoff's psychosis.

[ Q: 546 ] MRCPass - Neurology

A 17 year old boy with mild learning
disability presents for assessment. He was
apparently well 5 years ago, when he
developed jaundice which persisted for 4
months. He was found to have difficulty
speaking, walking up the stairs and he also
had choreoathetoid movements of the arms.

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On examination, there was jaundice, but no
clubbing, cyanosis or peripheral
lymphadenopathy. A neurological examination
showed weakness and wasting of muscles
acting on the shoulder and hip joints and brisk
deep reflexes. The plantar responses were
flexor. There were no extrapyramidal signs.
The patient had Kayser Fleisher rings
confirmed by slit-lamp examination.

What is the likely diagnosis?

1- New variant CJD

2- Alzheimer's disease

3- Motor neuron disease

4- Wilson's disease

5- Pick's disease

Answer & Comments

Answer: 4- Wilson's disease

Wilson disease is a rare autosomal recessive
inherited disorder of copper metabolism. The
condition is characterized by excessive
deposition of copper in the liver, brain, and
other tissues.

Wilson's disease usually presents at ages less
than 40. Hepatic dysfunction is the presenting
feature in more than half of patients. Apart
from hepatitis, neuropsychiatric presentation
and movement disorders are common
presentations. Kayser-Fleischer rings are
observed in up to 90% of individuals with
symptomatic Wilson disease.

Manifestations include dystonia,

choreoathetoid movements, spasticity, grand
mal seizures, rigidity, and flexion contractures.

[ Q: 547 ] MRCPass - Neurology

A 60 year old man is on high dose
prednisolone for a diagnosis of giant cell
arteritis 4 months ago. He complains of a
headache, which had worsened for the past
week and double vision.

On examination, there is neck stiffness, and
right sided 7th nerve palsy. His temperature is
38 degrees. A lumbar puncture reveals a
protein of 0.8 g/l, glucose of 3.5, WCC of 30
(predominant neutrophils).

What is the most likely causative organism?

1- Listeria monocytogenes

2- Mycobacterium tuberculosis

3- Mycoplasma pneumoniae

4- Borrelia burgdoferi

5- Herpes simplex

Answer & Comments

Answer: 1- Listeria monocytogenes

The lumbar puncture findings are consistent
with a bacterial meningitis but the glucose is
not low enough to suggest TB. Listeria
monocytogenes is an aerobic and facultatively
anaerobic gram-positive bacillus. The risk of
listeriosis is markedly increased in immuno¬
compromised patients, particularly among
those undergoing renal transplantation,
receiving high doses of corticosteroids, or
suffering with AIDS or cancer.

Ampicillin or penicillin has generally been
recommended as the treatment of choice.

[ Q: 548 ] MRCPass - Neurology

A 45 year old lady presents with a
week's history of spontaneous, deep, right
shoulder pain radiating to the neck.

There is also weakness and then wasting of
the right deltoid, spinati and triceps muscles.

Which is the likely diagnosis?

1- Spinobulbar dystrophy

2- C5 and C6 myelopathy

3- Guillain barre syndrome

4- Rotator cuff tendonitis

5- Brachial neuritis

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Answer & Comments

Answer: 5- Brachial neuritis

Idiopathic brachial neuritis is an immune-
mediated disorder, often preceded by an
upper respiratory tract infection or
immunisation. The initial feature is the abrupt
onset of unilateral arm pain or shoulder pain.
There is also evolving weakness, which is
worst 2-3 weeks after the onset of pain.

take at least two paracetamol and two
tramadol tablets per day.

Which is the likely diagnosis?

1- Cluster headaches

2- Analgesic induced headaches

3- Migrainous headaches

4- Space occupying tumour

5- Trigeminal neuralgia

[ Q: 549 ] MRCPass - Neurology

A 60 year old man presents with
difficulty with his mobility. He has increased
tone, bradykinesia, a pill rolling tremor and a
shuffling gait.

Which medication should be commenced first?

1- Benztropine

2- Amantadine

3- Selegiline

4- Apomorphine

5- Co-careldopa

Answer & Comments

Answer: 2- Analgesic induced headaches

Frequent use of some immediate-relief
medications can result in recurring or
persistent headache in those with pre-existing
headache and an individual susceptibility.
Three or more simple analgesics (aspirin and/
or acetaminophen) a day (more than 1000
mg) more often than 5 days a week.

Frequent use of short-acting NSAIDs such as
ibuprofen and also opiate based drugs can
also be a cause.

Answer & Comments

[ Q: 551 ] MRCPass - Neurology

Answer: 5- Co-careldopa

t\]

1 -S

A 60 year old patient has diplopia

Co-careldopa is the first medication used to
increase dopaminergic activity in the basal
ganglia. Apomorphine is used for on-off
fluctuations. Benztropine is used for
anticholinergic side effects. Selegiline is an
MAO inhibitor, and Amantadine is an antiviral
drug. Both are used as a second line drugs.
Apomorphine is used for on-off fluctuations.

[ Q: 550 ] MRCPass - Neurology

A 50 year old man presents with a 5
year history of headaches. The pain has
gradually worsened and is now present daily,
particularly on waking. He describes the pain
as dull, generalised and constant. It is
exacerbated by bright light. Neurological
examination is unremarkable. She needs to

looking to the left. When the left eye is
covered, the outer image disappears.

Which nerve is involved?

1- Left abducens

2- Right abducens

3- Left trochlear

4- Right trochlear

5- Left oculomotor

Answer & Comments

Answer: 1- Left abducens

Covering the affected eye causes the false
image (outer image) to disappear. In this case,
the left eye is involved hence left lateral rectus
(abducens nerve).

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[ Q: 552 ] MRCPass - Neurology

f | -

# A 22 year old man had an accident 3
years ago. During that time he was
documented to have a T12 lesion on the spinal
cord. He now presents with numbness on his
trunk.

On examination, there is reduced sensation to
pin prick from T6 to T10.

What is the most likely cause of this?

1- Brown sequard syndrome

2- Subacute combined degeneration of the
cord

3- Anterior spinal artery thrombosis

4- Post traumatic syrinx

5- Arteriovenous malformation

Answer & Comments

Answer: 4- Post traumatic syrinx

elevated CSF pressure but the constituents of
CSF are normal.

In this particular patient , which of the
Following would suggest that a complication
has arisen?

1- Bitemporal hemianopia

2- Loss of colour vision

3- 4th nerve palsy

4- Visual loss

5- Torticollis

Answer & Comments

Answer: 4- Visual loss

The diagnosis is idiopathic intracranial
hypertension (benign intracranial

hypertesion).

In this condition papilloedema may result in
an enlarged blind spot.

Post traumatic syringomyelia (PTS) refers to
the development and progression of a cyst
filled with cerebrospinal fluid (CSF) within the
spinal cord. Other symptoms include
increased weakness, numbness, increased
spasticity, and hyperhidrosis (increased sw
eating).

Ascending sensory level and sensory
dissociation (selective loss of pain and
temperature sensation) are very sensitive
indicators for detecting progressive PTS. MRI
is the preferred initial imaging study for the
diagnosis of PTS.

[ Q: 553 ] MRCPass - Neurology

A 42 year old woman presents with a
history of headaches. She also reports
menstrual irregularities. On examination, she
was noted to be obese. Fundoscopy revealed
bilateral papilloedema. Tone, power and
reflexes in the limbs were normal.

Investigations show a normal CT scan and
MRI. EEG normal. Lumbar puncture reveals

Uniocular visual loss would suggest infarction
of the optic nerve consequent on severe and
long standing papilloedema.

[ Q: 554 ] MRCPass - Neurology

A 70 year old man presents with
sudden onset dysphagia and dysarthria,
vomiting hiccup and vertigo.

On examination he has a right sided Horner's
syndrome, right-sided cerebellar ataxia, loss of
pain and temperature sensation on the right
hand side of the face and loss of pain and
temperature sensation in the left upper and
lower limbs.

Where is the lesion?

1- Pons

2- Lateral medulla

3- Cerebellum

4- Midbrain

5- Tectum

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Answer & Comments

Answer: 2- Lateral medulla

The patient has the lateral medullary
syndrome.

2- Neurocysticercosis

3- Multiple sclerosis

4- Cerebral toxoplasmosis

5- Tuberculosis

Multiple areas are involved : 9th and 10th
nerve - dysphagia and dysarthria Vestibular
nuclei - vertigo Inferior cerebellar peduncle -
ipsilateral cerebellar ataxia Descending
autonomic fibres - Horner's syndrome Fifth
nerve nucleus - loss of pain and temperature
sensation over the face (ipsilateral) Lateral
leminiscus - loss of pain and temperature
sensation in the contralateral limbs

Answer & Comments

Answer: 2- Neurocysticercosis

Neurocysticercosis is caused by Taenia solium
(pork tapew orm). There may be seizures due
to localised inflammation that accompanies
their degeneration in the cerebral cortex
when calcified cysts occur. This disease is
found in South America and Asia.

[ Q: 555 ] MRCPass - Neurology

A patient presents with weakness of
knee extension and ankle inversion.

Which of the Following nerve roots could be
damaged?

Neurocysticercosis typically is benign, and
most lesions resolve spontaneously within 2-3
months. An enzymelinked immunotransfer
blot (EITB) assay of a patient's serum may
confirm the diagnosis. Albendazole is the
recommended treatment.

1- L2

2- L3

3- L4

4- L5

5- SI

Answer & Comments

Answer: 3- L4

L4 is involved in knee extension and ankle
inversion. The tibial nerve carries L4 & L5
roots.

[ Q: 556 ] MRCPass - Neurology

A 25 year old man has come from
Mexico 5 years ago. Since a year ago, he has
had two tonic clonic seizures a week.

On examination, he appears well, with no
focal neurological deficit. A CT scan shows
multiple calcified cystic lesions in the brain.

Which diagnosis is likely?

1- Neurosarcoid

Neurocysticercosis

[ Q: 557 ] MRCPass - Neurology

A 42 year old lady presents with
weakness, diplopia and fatigue. She has a past
medical history of rheumatoid arthritis.

On examination there was bilateral partial
ptosis and weakness of abduction of both
eyes.

What is the likely diagnosis?

1- Myasthenia gravis

2- Mononeuritis multiplex

3- Guillain Barre syndrome

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4- Paraneoplastic syndrome

5- Lambert Eaton myasthenic syndrome

Answer & Comments

Answer: 1- Myasthenia gravis

The most likely diagnosis is myasthenia gravis.
There is an association between myasthenia
gravis, pernicious anaemia, systemic lupus
erythematosis and rheumatoid arthritis. The
condition is more common in women with a
peak incidence around the age of 30. It
characterised by fatiguability of the proximal
limb muscles, ocular and bulbar muscles.
Reflexes are initially preserved but may be
fatiguable.

may, for example, cause sudden outbursts of
unexpected aggression or agitation, or it may
be characterized by aura-like phenomena.

Complex partial seizures are characterized by
impaired aw areness. They lose awareness
and tend to have a motionless stare
accompanied by automatisms -- stereotyped,
repetitive, involuntary movements such as lip
smacking, chew ing, picking at objects,
scratching, and gesturing.

In some cases, a series of old memories
resurfaces. Hallucinations of voices, music,
people, smells, or tastes may occur. These
features are called "auras" or "warnings."
They may last for just a few seconds, or may
continue as long as a minute or two.

[ Q: 558 ] MRCPass - Neurology

A 30 year old man presents with a 6
month history of recurrent episodes altered
beaviour. During these episodes, he develops
a motionless stare with associated lip
smacking, grimacing, chewing movements,
scratching or gesturing. His partner describes
him as having labile emotions, he may get
sudden outbursts of aggression or agitation.

Which of the Following is the likely diagnosis?

1- Transient global amnesia

2- Frontal lobe epilepsy

3- Temporal lobe epilepsy

4- Parietal lobe lesion

5- Migraine

Answer & Comments

Answer: 3- Temporal lobe epilepsy

The features of seizures beginning in the
temporal lobe can be extremely varied, but
certain patterns are common. In temporal
lobe epilepsy, there may be a mixture of
different feelings, emotions, thoughts, and
experiences, which may be familiar or
completely foreign. Temporal lobe epilepsy

Carbamazepine and phenytoin are used to
treat the condition.

[ Q: 559 ] MRCPass - Neurology

A 55 year old drug user who is
homeless presents with lethargy. General
examination reveals poor hygiene and a sacral
sore. He has bilateral ptosis, and difficulty
swallowing. There is also general weakness in
all limbs. His lethargy is worse in the evenings.

Which of the Following is the likely diagnosis?

1- Myasthenia gravis

2- Lambert eaton myasthenic syndrome

3- Botulism

4- Motor neuron disease

5- HIV neuropathy

Answer & Comments

Answer: 3- Botulism

The main differentials are myasthenia gravis,
LEMS and botulism, but in this context
botulism is more likely. Botulism is a paralytic
disease caused by the neurotoxins of
Clostridium botulinum. Wound botulism,
caused by systemic spread of toxin produced

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by organisms inhabiting wounds, trauma,
surgery and subcutaneous heroin injection.

The neurologic symptomatology often has
been described as a progressive, descending
weakness or paralysis that affects muscles
innervated by the cranial nerves. Respiratory
difficulty arises from airway obstruction and
diaphragmatic weakness. Diplopia, dysarthria,
dry mouth, and generalized weakness are
among the most common presenting
symptoms.

hearing loss and vertigo. On examination, he
has an absent corneal reflex on the left. There
is also mild left sided facial weakness.

Which one of the Following is most likely?

1- Frontal lobe tumour

2- Cavernous sinus thrombosis

3- Ramsay Hunt syndrome

4- Cerebellopontine angle tumour

5- Syringomyelia

[ Q: 560 ] MRCPass - Neurology

A 50 year old teacher develops a
sided facial weakness in association with
hearing loss and pain in the right ear.

On examination, there is a vesicular rash over
the right ear, and right lower motor neuron
7th nerve palsy.

Whot is the likely couse?

1- Lyme disease

2- Herpes zoster

3- Diabetes

4- Polyarteritis nodosa

5- Syphilis

Answer & Comments

Answer: 2- Herpes zoster

This is Ramsay-Hunt syndrome. The primary
pathophysiology of Ramsay Hunt syndrome is
located in the geniculate ganglion of the
seventh cranial nerve (CN VII).

Classically, Ramsay Hunt syndrome has been
associated with VZV. It is associated with 7th
nerve palsy, vertigo, ipsilateral hearing loss
and tinnitus.

Answer & Comments

Answer: 4- Cerebellopontine angle tumour

Cerebellopontine angle (CPA) tumors can
cause vertigo, unilateral hearing loss. Large
tumors may cause subtle facial weakness,
decreased corneal reflex, and facial
dysesthesia. If there was opthalmoplegia or
chemosis, then a cavernous sinus thrombosis
would be more likely (it can also cause absent
corneal reflexes).

[ Q: 562 ] MRCPass - Neurology

A 60 year old woman with headache
and nausea is suspected of having posterior
cerebral artery thrombosis.

Which of the Following is o recognised feature
of this occurrence?

1- Cerebellar ataxia

2- Hemiparesis

3- Homonymous hemianopia

4- Third nerve palsy

5- Sixth nerve palsy

Answer & Comments

Answer: 3- Homonymous hemianopia

[ Q: 561 ] MRCPass - Neurology
A 55 year old man has left sided

The posterior cerebral artery supplies the
occipital lobe and occlusion causes damage to
the visual cortex, resulting in homonymous
hemianopia.

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Posterior Cerebral Artery Infarct

[ Q: 563 ] MRCPass - Neurology

A 35 year old woman wakes up with
a sudden onset severe sharp headache. She
has no neurological signs. CT of her head is
normal.

Whot is the best next investigation?

1- MRV

2- Lumbar puncture

3- Serum electrophoresis

4- EEG

5- Bone scan

Answer & Comments

Answer: 2- Lumbar puncture

The diagnosis of subarachnoid haemorrhage
needs to be exclude in a patient with acute
sudden onset severe headache. The CSF
sample should be sent for xanthochromia.
Lumbar puncture is recommended 12 hours
after the event to allow xanthochromia to
develop. It is a yellow ish pigment (subtle and
needs spectrophotometry) which indicates the
presence of bilirubin in the CSF.

[ Q: 564 ] MRCPass - Neurology

A 30 year old man has a history of
epilepsy. He was found on the street having a
seizure and was brought to A+E. Rectal

diazepam had been given by the ambulance
crew. His seizure lasts more than 15 minutes.

What is the best management step?

1- Intravenous lorazepam

2- Intravenous phenytoin

3- Oral carbamazepine

4- Intravenous phenobarbitone

5- CT scan of the head

Answer & Comments

Answer: 2- Intravenous phenytoin

This patient has status epilepticus. He has not
responded to a benzodiazepine and hence the
next step is to load with intravenous
phenytoin at a dose of 15mg/kg.

[ Q: 565 ] MRCPass - Neurology

A 60 year old man is a vegetarian
and presents with lethargy. He has frequent
diarrhoea and mentions that he eats mostly
maize.

On examination, he has an erythematous rash
across his face and chest. He is confused and
disorientated. On examination, he has an
MMSE score of 21 /30. Tone and reflexes are
normal but he weak throughout the body.

Which vitamin is his diet likely to be deficient?

1- Thiamine

2- B12

3- Niacin

4- Vitamin C

5- Vitamin A

Answer & Comments

Answer: 3- Niacin

The diagnosis is pellagra. There is a triad of
dementia, diarrhoea and dermatitis. Niacin
(nicotinamide or nicotinic acid) deficiency
causes pellagra only if tryptophan, an amino

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acid, is also deficient. People who live in areas
where maize (Indian corn) is the main food
source are at risk of developing pellagra
because maize is low in niacin and tryptophan.

Pellagra affects the skin, digestive tract, and
brain. A photosensitive rash may occur. Skin
abnormalities are persistent, and the affected
areas may become brown and scaly.

The whole digestive tract is affected. Other
symptoms include nausea, vomiting,
constipation, and diarrhea. Later, fatigue,
insomnia, and apathy develop.
Encephalopathy usually follows. It is
characterized by confusion, disorientation,
hallucinations, and memory loss.

Photosensitive rash seen in Pellagra

[ Q: 566 ] MRCPass - Neurology

A 45 year old woman has sensory
loss and wasting of the small hand muscles.
One examination, she also has a right sided
Horner's syndrome. Her arms demonstrate
thickening of the subcutaneous tissues. There
is also evidence of Charcot's joints on the
wrists.

What is the diagnosis?

1- Hereditary spinocerebellar ataxia

2- Hereditary spastic paraparesis

3- Motor neuron disease

4- Syringomyelia

5- Multiple sclerosis

Answer & Comments

Answer: 4- Syringomyelia

Syringomyelia is chronic disorder
characterised by the presence of glial-lined
cavities situated in the central part of the
spinal cord.

Recognised causes include Chiari type I
malformation, central cord tumours, basal
arachnoiditis and trauma.

There may be sensory loss, wasting of the
small hand muscles, uni- or bilateral Horner's
syndrome, abnormalities of sw eating,
thickening of subcutaneous tissues, atrophy
and decalcification of bones, development of
Charcot's joints and Chiari I malformation (due
to arachnoiditis).

[ Q: 567 ] MRCPass - Neurology

A 27 year old lady presents with a
severe headache, which woke her up from
sleep. She is not pregnant and was on no
drugs in particular she was not on hormonal
contraception. On examination she was
afebrile and alert. On examination of the optic
fundus the cup of the optic disc was filled and
the medial margins of the disc were blurred.
There was no other CNS abnormality, in
particular no neck stiffness. A CT scan was as
normal.

What is the likely diagnosis?

1- Meningioma

2- Sagittal sinus thrombosis

3- Benign intracranial hypertension

4- Migraine

5- Meningitis

Answer & Comments

Answer: 2- Sagittal sinus thrombosis

This is the most likely cause, despite not being
pregnant or on the OCP. In only 10% of cases
is cerebral venous thrombosis due to damage

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to the vessel wall by infection, tumour or
trauma.

Commonest causes are inherited disorders of
coagulation of which factor V Leiden mutation
is found in around 20% of cases. Often there is
combination of causative factors: e.g. protein
S deficiency and child birth, pregnancy and
Behcet's disease, OCP and factor V Leiden
mutation.

[ Q: 568 ] MRCPass - Neurology

A 25 year old female patient
presents with a 5-day history of ascending
muscle weakness in both hands and feet.
EMGs confirm acute demyelinating sensory
and motor neuropathy.

Whot treatment should be started?

1- Phenytoin

2- Diazepam

3- Amitriptyline

4- Intravenous immunoglobulin

5- Pyridostigmine

Answer & Comments

Answer: 4- Intravenous immunoglobulin

The diagnosis is Guillain Barre syndrome. It is
preceded by diarrhea (e.g. Campylobacter)
and chest infections (e.g. mycoplasma) in two
thirds of cases. Autonomic dysfunction and
hyporeflexia are associated. Studies have
shown that plasma exchange and IVIg are
equally effective in treating people within two
to four weeks of onset of GBS.

[ Q: 569 ] MRCPass - Neurology

A 32 year old man has difficulty with
his vision. On examination he has impaired
adduction of the right eye looking left. The left
eye has jerky nystagmus.

Which investigation is most likely to yield a
diagnosis?

1- Nerve conduction studies

2- CT of the head

3- Paired CSF and serum for oligoclonal bands

4- Serum copper and caeruloplasmin

5- Visual evoked potentials

Answer & Comments

Answer: 3- Paired CSF and serum for
oligoclonal bands

The clinical scenario is internuclear
ophthalmoplegia.

This is most commonly seen in multiple
sclerosis. MRI of the brain and CSF are the
best diagnostic tests. In this scenario the
lesion is in the right medial longitudinal
fasciculus.

Internuclear opthalmoplegia - patient looking

to the left

^ [ Q: 570 ] MRCPass - Neurology

f* -

# A patient has, on examination,
weakness in plantar flexion and foot inversion
on the left. He also is unable to tiptoe on the
same foot. Ankle jerk is absent.

Which nerve lesion is most likely?

1- Common peroneal nerve

2- L4 nerve root

3- Tibial nerve

4- Sciatic nerve

5- Femoral nerve

Answer & Comments

Answer: 3- Tibial nerve

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The tibial nerve supplies the gastrocnemius
muscle and leads to the above findings. The
common peroneal nerve causes weakness of
eversion and dorsiflexion.

[ Q: 571 ] MRCPass - Neurology

A 50 year old man has subjectively
diminished light touch and pinprick sensation
in the left hand extending to above the elbow.
Joint position sense is intact. He has difficulty
distinguishing a cigarette from a pen using the
right hand with his eyes closed. His two-point
discrimination is 11 mm.

Where is the lesion?

1- Anterior frontal

2- Posterior frontal

3- Anterior parietal

4- Posterior parietal

5- Cingulate gyrus

Answer & Comments

Answer: 3- Anterior parietal

The sensory signs described here are
indicative of a lesion of the anterior parietal
cortex (mid postcentral gyrus). The cingulate
gyrus is part of the limbic system (mood and
emotions).

[ Q: 572 ] MRCPass - Neurology

A 55 year old man has been
progressively getting more confused. His
symptoms began about three years ago when
he noticed leg stiffness. At present his entire
body feels stiff and he has a resting tremor in
the limbs. His w riting has become small. Over
the last six months, he has developed
hallucinations and reports seeing ghost
figures, and is also becoming forgetful, on one
occasion leaving the gas cooker fire on.

On examination, his mini-mental score was
10/30. He has increased tone throughout
which is spastic and cogw heeling. There is a

tremor in all limbs. Cranial nerve examination
reveals mild restriction of conjugate upgaze
eye movement. His gait was shuffling with a
tendency to fall backwards.

Whot is the most likely diagnosis?

1- Parkinson's disease

2- Pick's disease

3- Lewy body dementia

4- Huntington's disease

5- Motor neuron disease

Answer & Comments

Answer: 3- Lewy body dementia

The combination of progressive cognitive
decline, fluctuating symptoms, visual
hallucinations, extrapyramidal signs (rigidity
and bradykinesia more prominent than
tremor) suggest Lewy body dementia. It is
progressive. Patients are at risk of falls and
syncope. Symptoms and signs of lew y body
dementia probably result in part from
disruption of information flow from the
striatum to the neocortex, especially the
frontal

lobe.

The cause is multifactorial. Altered
neuromodulator and/or neurotransmitter
levels (eg, acetylcholine, dopamine) influence
the function of many neuronal circuits.

^ [ Q: 573 ] MRCPass - Neurology

# A 35 year old patient presented to
the hospital with generalised unsteadiness
and limb weakness. There was a history of
ascending weakness, beginning five days
before admission. On examination, she had
distal weakness with decreased reflexes in the
lower limbs.

She had a lumbar puncture. The results of the
CSF showed 7 x 10 9 /L lymphocytes, no
erythrocytes, and 1.2 g/l protein. EMGs
showed reduction of mean conduction

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velocity and prolonged distal latency (DL)
were observed in the median, ulnar, and tibial
nerves.

Whot is the diagnosis?

1- Multiple sclerosis

2- Viral meningitis

3- Syphilis

4- Trigeminal neuralgia

5- Guillain Barre syndrome

Answer & Comments

Answer: 5- Guillain Barre syndrome

Conditions such as viral meningitis and
multiple sclerosis cause mild protein elevation
(above 0.5g). However, Guillain Barre
syndrome causes marked protein elevation,
often approaching or more than lg.M

In Guillain Barre syndrome, there is acute
demyelination of the nerves, leading to
reduced conduction velocities on the EMGs.

[ Q: 574 ] MRCPass - Neurology

A 43 year old man presents with
frequent headaches and loss of libido. He was
found to have hypopituitarism on
investigation. The CT scan shows a pituitary
tumour with suprasellar extension.

Which of the Following structures is likely be
compressed?

1- Abducens nerve

2- Hypothalamus

3- Trochlear nerve

4- Optic chiasm

5- 3rd Ventricle

Answer & Comments

Answer: 4- Optic chiasm

Superior extension (suprasellar) of a pituitary
tumour can lead to compression and invasion
of the optic chiasm and nerve.

[ Q: 575 ] MRCPass - Neurology

A 32 year old woman has known
migraine. She gets periodic episodes of
headaches with associated visual symptoms.

Which one of the Following drugs should be
used first in a migraine attack?

1- Ibuprofen

2- Methysergide

3- Subcutaneous sumatriptan

4- Oral sumatriptan

5- Morphine

Answer & Comments

Answer: 1- Ibuprofen

In acute migraine attack, the first line
treatments are simple analgesics such as
aspirin, ibuprofen or paracetamol.

Second line treatment in acute migraine are
the triptans (e.g sumatriptan) which work by
selectively stimulating 5-hydroxytriptamine 1
(5HT1) receptors.

[ Q: 576 ] MRCPass - Neurology

A 30-year-old woman has an 18
month history of unsteady gait, difficulty to
speak and to perform fine movements with
the fingers. She has a history of moderate
alcohol intake.

Neurological examination showed scanning
dysarthria, horizontal nystagmus in the lateral
gaze, severe bilateral dysmetria in the upper
and lower limbs, bilateral dysdiadochokinesis,
severe gait ataxia and inability to maintain the
sitting.

What is the diagnosis?

1- Parkinson's disease

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2- Subacute combined degeneration

3- Cerebellar syndrome

4- Motor neuron disease

5- Myasthenia gravis

Answer & Comments

Answer: 3- Cerebellar syndrome

A mnemonic for cerebellar signs is VANISH'D -
Vertigo, Ataxia, Nystagmus, Intention tremor,
Scanning speech, Hypotonia and
Dysdiadochokinesis.

Cerebellar syndromes are commonly due to
alcohol, cerebellar space occupying lesions,
multiple sclerosis, and rarely, inherited
sydromes such as Friedrich's Ataxia or
Spinocerebellar ataxia.

[ Q: 577 ] MRCPass - Neurology

A 30 year old man presents with a 5
day history of weakness in the arms and legs,
accompanied by tingling. He had several
episodes of bloody diarrhoea illness two
weeks ago.

On examination there was leg and arm
weakness and flaccid deep tendon reflexes.

Which test would best help confirm the
diagnosis?

1- EMG

2- EEG

3- MRI

4- HIV serology

5- Anti Ach antibody

Answer & Comments

Answer: 1- EMG

The diagnosis is likely to be Guillain Barre
syndrome. The two best tests are EMG (shows
acute demyelination changes) and CSF (raised
protein). Campylobacter serology should also
be sent for this patient.

[ Q: 578 ] MRCPass - Neurology

A 70 year old man who had multiple
episodes of unilateral amaurosis fugax. He has
risk factors of being a smoker and
hypertension. He is on atenolol and aspirin.

An ECG shows atrial fibrillation. Carotid
dopplers show 80% right carotid stenosis.

What is the most appropriate management?

1- Warfarin

2- Carotidendarterectomy, then warfarinise

3- Clopidogrel

4- High dose aspirin 300mg with a proton
pump inhibitor

5- Tight hypertensive control

Answer & Comments

Answer: 2- Carotidendarterectomy, then
warfarinise

As there is > 70% carotid artery stenosis and
symptoms suggestive of emboli,
endarterectomy is recommended. The patient
should also be anticoagulated afterwards in
view of atrial fibrillation.

[ Q: 579 ] MRCPass - Neurology

A 50 year old man has a history of
hypertension and is a smoker. He complains of
visual loss. Assessment shows the presence of
a right homonymous hemianopia.

Which structure is damaged?

1- Optic chiasm

2- Optic radiation

3- Left occipital lobe

4- Right occipital lobe

5- Temporal lobe

Answer & Comments

Answer: 3- Left occipital lobe

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In homonymous hemianopia, the contralateral
occipital lobe is affected (usually infarct).

Left occipital infarct on MRI

[ Q: 580 ] MRCPass - Neurology

A 66 year old man has had
longstanding tremors in both his hands and
forearms. Examination reveals normal tone,
power and reflexes in his arms. The tremors
improve when he drinks alcohol.

Whot is the diagnosis?

1- Parkinson's disease

2- Motor neuron disease

3- Benign essential tremor

4- Prion infection

5- Hemiballismus

Answer & Comments

Answer: 3- Benign essential tremor

The Following features support a diagnosis of
Essential Tremor:

(1) bilateral action tremor of the hands and
forearms

(2) absence of other neurological signs, except
the cogw heel phenomenon

(3) may have isolated head tremor with no
signs of dystonia

Secondary criteria include a long disease
duration (more than three years), a positive
family history and beneficial response to
alcohol (not anticholinergics).

^ [ Q: 581 ] MRCPass - Neurology

# A 45 year old man has difficulty
getting out of the chair.

On examination, he has proximal muscle
weakness.

Investigations show :

Hb 12.5 g/dl

MCV 79 fl

WCC 7 x 10 9 /L

platelets 220 x 10 9 /L

urea 6 mmol/l

creatinine 110 pmol/l

Creatine Kinase 7,000 (24-170) U/l

What investigation should be done next?

1- Lumbar puncture

2- CT brain

3- MRI brain

4- Muscle biopsy

5- Tensilon test

Answer & Comments

Answer: 4- Muscle biopsy

The clinical features are consistent with
dermatomyositis or polymyositis.

A suitable area should be identified by
electromyography for muscle biopsy. Muscle
biopsy shows muscle necrosis, phagocytosis of
muscle fibres, and an inflammatory infiltrate.

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Polymyositis - Inflammatory infiltrates in a

muscle biopsy

[ Q: 582 ] MRCPass - Neurology

A 50 year old lady complains of
gradual onset of blurred vision in her left eye.
Examination reveals a left sided relative
afferent pupillary defect. Fundoscopy reveals
left sided optic atrophy. Visual fields show a
left sided central scotoma and an upper
quadrantic visual field defect in the right eye.

Where is the lesion?

1- Left optic nerve

2- Left anterior optic chiasm

3- Sphenoid wing

4- Left occipital area

5- Left optic radiation

Answer & Comments

Answer: 2- Left anterior optic chiasm

Lesions of the anterior chiasm (junction of
optic nerve and chiasm) will produce an
ipsilateral central scotoma and a contralateral
superior quadrantanopia. The contralateral
defect is due to interruption of the crossing
nasal fibres.

Left v Sufll I ifrld

Left eye

Oplic

chiasm

Ekain

R icjhi visual Field

Right aye

Optic

rwrve

Optic Tract

[ Q: 583 ] MRCPass - Neurology

A 40 year old patient has been
having fevers, neck stiffness and confusion.
There was a past medical history of HIV
infection and diabetes.

A CT scan was normal and lumbar puncture
was performed. The opening pressure during
LP was normal, and there were elevated CSF
lymphocytes (88), and elevated CSF protein
(5.5 g/l), and a low glucose. Gram staining and
India ink preparation revealed 4-7?m, round
budding yeasts with capsule and 8-10
lymphocytes per high power field.

What is the diagnosis?

1- Mumps meningitis

2- Mycobacterium tuberculosis

3- Cryptococcal meningitis

4- Carcinomatous meningitis

5- Meningococcal meningitis

Answer & Comments

Answer: 3- Cryptococcal meningitis

Cryptococcal meningitis is often seen in
immunosuppressed patients. The organism is

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Cryptococcus Neoformans. Meningitis
manifests with diffuse, nonfocal findings (eg,
altered mental status, vomiting).

A CT scan or MRI in patients with cryptococcal
infection may reveal diffuse atrophy or
cerebral edema with focal, homogenous, or
contrast-enhanced areas.

An India ink preparation is commonly used
with CSF to identify the organism and to
support a presumptive diagnosis. If performed
correctly, 25-50% of patients with
cryptococcal meningitis show cryptococci.

In patients with AIDS, amphotericin B is given
for 2 weeks, with or without 2 weeks of
flucytosine, followed by fluconazole at 400
mg/d for a minimum of 10 weeks.

[ Q: 584 ] MRCPass - Neurology

A young lady visits her neurologist
complaining of episodes of generalised
weakness after arguments with her partner.
She also complains of seeing goblins upon
waking up. At work as a secretary, she has
difficulty staying awake and may have sleep
attacks.

Whot is the likely diagnosis?

1- Narcolepsy

2- Generalised epilepsy

3- Petit mal seizures

4- Obstructive sleep apnoea

5- Jacksonian seizures

Answer & Comments

Answer: 1- Narcolepsy

The condition described is narcolepsy. The
episodes described are likely to be cataplexy.

The HLA association is DQB1, Clomipramine is
a tricyclic antidepressant which may help,
there is early REM sleep and hypnagogic
hallucinations occur.

[ Q: 585 ] MRCPass - Neurology

A 68 year old woman has neck pains
and occipital headaches for 2 years. She is
referred to the neurology outpatients for
assessment. Investigations showed a normal
CT of the brain. Cervical X ray showed
degenerative changes of narrow ed disc
spaces and loss of cervical lordosis.

Whot is the likely diagnosis?

1- Cerebellar haemorrhage

2- Temporal arteritis

3- Occipital neuralgia

4- Epidural haemorrhage

5- Cervical spondylosis

Answer & Comments

Answer: 5- Cervical spondylosis

In cervical spondylosis, several overlapping
syndromes are seen: neck and shoulder pain,
suboccipital pain and headache, radicular
symptoms, and cervical spondylotic
myelopathy.

Examination findings include neck pain,
radicular signs, and myelopathic signs. Cervical
spine films can demonstrate disk space
narrow ing, osteophytosis, loss of cervical
lordosis, uncovertebral joint hypertrophy,
apophyseal joint osteoarthritis, and vertebral
canal diameter.

[ Q: 586 ] MRCPass - Neurology

r -

* A 45 year old woman is referred to
you for investigation of headache. She has had
headaches for 10 years.

Initially it responded to proprietary painkillers,
but she is currently using the maximum dose
of paracetamol, tramadol and diclofenac. The
headaches are frequent throughout the day
and last for hours. There are no associated
visual symptoms.

Which is the next best management step?

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1- Iv aspirin

2- Caffeine

3- Withdrawal of analgesics

4- Pizotifen

5- Sumatriptan

Answer & Comments

Answer: 3- Withdrawal of analgesics

The history of chronic use of analgesics and
nature of headaches suggests analgesic
induced headache. In some patients the
headaches will improve.

[ Q: 587 ] MRCPass - Neurology

A patient is undergoing examination
of the eye. The patient has a direct response
to light shone in the right eye, but no
consensual response. Light shone in the left
eye elicits a consensual response, but not a
direct response.

During pursuit eye movements, the left eye is
fixed in an inferior and lateral position.

Where is the lesion?

1- Right trochlear nerve

2- Left optic nerve

3- Left oculomotor nerve

4- Right abducents nerve

5- Left trochlear nerve

Answer & Comments

Answer: 3- Left oculomotor nerve

A left third nerve palsy will cause a dilated left
pupil, with the eye in a 'down and out'
position. The afferent pathway is controlled by
the optic nerve and the efferent pathway by
the oculomotor nerve - hence a dilated poorly
reacting pupil.

Left Third Nerve Palsy

[ Q: 588 ] MRCPass - Neurology

A 18 year old male is wheelchair
bound and has difficulty with respiration. He
also has upper limb weakness.

When he was younger he developed marked
hypertrophy of his muscles. Blood tests reveal
a raised creatine kinase.

What is a muscle biopsy likely to show?

1- Necrotic muscle fibres

2- Absence of dystrophin

3- Excessive lipid storage

4- Macrophage infiltration

5- Vasculitic changes

Answer & Comments

Answer: 2- Absence of dystrophin

Mutation in the dystrophin gene causes
deficiency of dystrophin in Duchenne's
muscular dystrophy. Patients develop
progressive upper and lower limb weakness
with pseudohypertrophy of calves and
quadriceps.

[ Q: 589 ] MRCPass - Neurology

A 30 year old lady is found to have a
left sided posterior communicating artery
aneurysm on cerebral angiography.

Which of the Following would you expect to
find?

1- Facial nerve palsy

2- Left pupillary constriction

3- Sensory loss to the left side of the face

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4- Downgaze palsy

5- Third nerve palsy

Answer & Comments

Answer: 5- Third nerve palsy

A posterior communicating artery aneurysm
will cause compression of the third nerve, and
therefore pupillary involvement from
compression of the parasympathetic fibres
that run on the outside of the third nerve. This
leads to a dilated pupil. Other features of a
third nerve palsy include ptosis, and a 'down
and out' eye. Upgaze and adduction is
affected.

on MRI in association with white matter
changes, the most likely cause would be a
demyelinating lesion.

Large lesions such as these can cause
weakness or cranial nerve defects.

[ Q: 590 ] MRCPass - Neurology

A 35 year old teacher has a right
sided headache and blurring of her vision in
the right eye. She has previously had an
episode of optic neuritis 3 years beforehand,
in the right eye. On examination, there was a
right afferent pupillary defect and pale optic
disc. There was weakness of the facial muscles
on the right. Tone and reflexes were brisk on
the right with power of 3/5 in the arm and the
leg. She was apyrexial.

MRI of the brain reveals a 4 cm left temporo¬
parietal mass, which was incompletely ring
enhancing. There were also two small white
matter lesions also visible in the frontal area.

What is the most likely diagnosis?

1- Cerebral lymphoma

2- Multiple sclerosis

3- Acute demyelinating encephalomyelitis

4- Lyme disease

5- Sarcoidosis

White matter lesions on MRI seen in multiple

sclerosis

[ Q: 591 ] MRCPass - Neurology

A 75 year old man has dysphasia and
left sided arm weakness. He is known to have
hypertension, asthma and rheumatoid
arthritis. In addition he suffered from cluster
headaches. He smokes 20 cigarettes a day.

On examination, he has some weakness of the
left hand. Visual fields, speech and sensation
are normal. Blood pressure is 190/90 mmHg.

Which of the Following is most likely?

1- Partial posterior circulation infarct

2- Right hemisphere lacunar infarct

3- Right pontine haemorrhage

4- Total anterior circulation infarct

5- Vertebrobasilar insufficiency

Answer & Comments

Answer: 2- Right hemisphere lacunar infarct

Answer & Comments

Answer: 2- Multiple sclerosis

The episodes of optic neuritis are suggestive
of MS. In view of the appearance of the lesion

The history suggests the dysarthria-clumsy
hand syndrome, one of the classic lacunar
syndromes that are strokes in the subcortical
regions (or brain stem) secondary to small
vessel disease. The usual site of damage in the

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dysarthria-clumsy hand syndrome is the
internal capsule or pons.

Answer & Comments

Answer: 5- IV lorazepam

^ [ Q: 592 ] MRCPass - Neurology

n -

# A 65 year old lady presents to the
hospital with an ataxic gait. On examination,
the patient had difficulty standing without
assistance and minor movements of her head
and body caused vertigo. There was mild
postural tremor and marked hypotonia of the
right limbs, mostly the arm.

Finger to nose testing elicited marked
intention tremor and disdiadochokinesis in the
right arm. Speech was dysarthric but
comprehension was good.

Where is the lesion likely to be?

1- Right pons

2- Left medulla

3- Right cerebellar hemisphere

4- Corpus callosum

5- Right basal ganglia

Current consensus is that a benzodiazepine,
notably lorazepam (Ativan), is the initial class
of drug for the treatment of status epilepticus.
A phenytoin, phenytoin sodium or
fosphenytoin is the next drug to be
administered.

^ [ Q: 594 ] MRCPass - Neurology

# A 28 year old woman is 30 weeks
pregnant. She complains of a sudden onset
generalised headache.

On examination, she has pupils are which
reactive bilaterally and there is a right sided
third nerve palsy.

Which test is most appropriate?

1- MRA

2- MRV

3- MRI

4- CT head

Answer & Comments

Answer: 3- Right cerebellar hemisphere

Lesions of the cerebellum (intention tremor,
disdiadochokinesis) lead to motor signs
ipsilateral to the lesion.

[ Q: 593 ] MRCPass - Neurology

A 25 year old man is known to have
epilepsy. He had a generalized tonic clonic
seizures for 15 minutes.

What drug should be given?

1- IV phenytoin

2- IV sodium valproate

3- IV gabapentin

4- IV lamotrigine

5- IV lorazepam

5- Lumbar puncture

Answer & Comments

Answer: 2- MRV

A headache in a pregnant patient, with
associated cranial nerve palsy suggests
cerebral venous sinus thrombosis. Treatment
is with intravenous or low molecular weight
heparin.

[ Q: 595 ] MRCPass - Neurology

A 45 year old man has severe
episodes of dizziness with associated vomiting
and pain in the right ear. This occurs once or
twice a week. During these attacks he feels
the surrounding environment spinning
around. He also mentions a high pitched
sound frequently being present.

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On examination, during an attack, he has right
horizontal nystagmus. Audiological testing
reveals right-sided sensorineural deafness.

Whot is the diagnosis?

1- Vestibular nystagmus

2- Meniere's disease

3- Benign paroxysmal positional vertigo

4- Acoustic neuroma

5- Cerebellopontine angle tumour

Answer & Comments

Answer: 2- Meniere's disease

Meniere's disease is caused by distension of
the endolymphatic compartment of the inner
ear. The symptoms of Meniere's disease
include vertigo, hearing loss and tinnitus. The
dizziness is described as a spinning or whirling
feeling and may cause problems with balance.
Some people feel nauseated and vomit during
an attack. Tinnitus refers to a ringing or
roaring sound in the ear. Others may notice
some hearing loss, especially with sounds that
have a low frequency.

Horizontal nystagmus is more commonly seen
on examination, but vertical nystagmus may
also occur.

[ Q: 596 ] MRCPass - Neurology

A 30 year old gynmast has sudden
onset vertigo and dizziness. On examination,
there is horizontal nystagmus, with a full
range of eye movements. Her speech is
slurred. There is intention tremor and
disdiadochokinesis which is asymmetrical. She
has an ataxic gait.

Which of the Following investigations would
be most appropriate?

1- CT of the head

2- MRI and MRA of head and neck

3- MRI with enhancement

4- Lumbar puncture

5- Otological testing

Answer & Comments

Answer: 2- MRI and MRA of head and neck

The clinical picture is of an acute onset
cerebellar syndrome, which suggest a vascular
cause. This would involve the posterior
(vertebrobasilar) circulation. If headache or
neck pain were associated, a vertebral artery
dissection w ould be most important to
exclude. A Magnetic Resonance Angiography
(MRA) will help to diagnose dissection,
stenosis or thrombosis.

[ Q: 597 ] MRCPass - Neurology

A 30 year old gym instructor
complained of shoulder pain and weakness
which has been progressive over the past 5
years. He is upset about having difficulty lifting
weights which he had previously been able to
do so without difficulty.

On examination, there was winging of the
scapula. Power was reduced in the muscles
around the shoulder, with bilateral wasting.
He also has some facial difficulty raising his
eyebrow s. His serum CK is 400.

What is the likely diagnosis?

1- Duchenne's muscular dystrophy

2- Becker's muscular dystrophy

3- Myotonic dystrophy

4- Fascioscapulo humeral dystrophy

5- Polymyalgia rheumatica

Answer & Comments

Answer: 4- Fascioscapulo humeral dystrophy

Facioscapulohumeral dystrophy (FSHD) is one
of the most common types of muscular
dystrophy. It is of autosomal dominant
inheritance. Onset is usually age 20 years.

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Initial weakness is seen in facial muscles,
starting in the orbicularis oculi, orbicularis
oris, and zygomaticus.

Shoulder weakness is the presenting symptom
in more than 82% of patients. Winging of the
scapula is the most characteristic sign.
Creatine kinase levels are raised. The drug
Albuterol which relaxes bronchial smooth
muscle has been shown to increase lean
muscle mass when used over a period of
months.

Winging of the scapula in FSHD

[ Q: 598 ] MRCPass - Neurology

A 40 year old man presented with
double vision and was found to have normal
vertical eye movements.

On left lateral gaze, there was absence of
adduction of the right eye, and nystagmus in
the abducting left eye.

This eye movement disorder con be explained
by o lesion in the:

1- Left cerebellopontine angle

2- Right parietal area

3- Right medial longitudinal fasciculus

4- Left medial longitudinal fasciculus

5- Left lateral medulla

Answer & Comments

Answer: 3- Right medial longitudinal fasciculus

The diagnosis is right internuclear
ophthalmoplegia due to a lesion in the right
medial longitudinal fasciculus. The likely
underlying pathology is multiple sclerosis,
other causes of INO include a glioma or
vascular lesion.

[ Q: 599 ] MRCPass - Neurology

A 70 year old man presents with a
history of falls. He has difficulty reading and
walking down stairs. He has dysarthria,
akinesia and rigidity. Power of the muscles is
normal, reflexes are brisk.

Whot physical sign will help to confirm the
diagnosis?

1- Gait

2- Eye movements

3- Romberg's sign

4- Abdominal reflexes

5- Plantar reflexes

Answer & Comments

Answer: 2- Eye movements

The patient has progressive supranuclear
palsy - parkinsonian features and gaze palsy.
Demonstration of impairment of voluntary
gaze will help confirm the diagnosis.

[ Q: 600 ] MRCPass - Neurology

A 55 year old man has slowly
progressive weakness of his upper limbs. On
examination of the patient the physical signs
are wasting and weakness of the small
muscles of the hand, flattening of the muscles
of the ulnar border of the forearm.

The upper limb reflexes are absent. Pain and
temperature sensation are reduced over the
upper limbs and upper chest whereas light
touch and proprioception remain intact.
Lower limb reflexes are exaggerated and
plantars are extensor.

What is the likely diagnosis?

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1- Normal pressure hydrocephalus

2- Multiple sclerosis

3- Arnold Chiari malformation

4- Severe kyphoscoliosis

5- Kennedy's syndrome

Answer & Comments

Answer: 3- Arnold Chiari malformation

kidney disease. There is a family history of the
condition.

What is the likely diagnosis?

1- Phaeochromocytoma

2- Von Hippel Lindau syndrome

3- Hereditary haemorrhagic telangiectasia

4- Multiple sclerosis

5- Friedriech's ataxia

Arnold-Chiari Malformation is a condition in
which the cerebellum portion of the brain
protrudes into the spinal canal. It may or may
not be apparent at birth.

Arnold-Chiari I type malformation usually
causes symptoms in young adults and is often
associated with syringomyelia, in which a
tubular cavity develops within the spinal cord.

Arnold-Chiari II type malformation is
associated with myelomeningocele (a defect
of the spine) and hydrocephalus (increased
cerebrospinal fluid and pressure within the
brain), which usually are apparent at birth.
The patient described has the features of an
intramedullary lesion of the spinal cord.

Chiari Malformation

—

[ Q: 601 ] MRCPass - Neurology

• l

1 J

A 30 year old woman has been

diagnosed with a cerebellar cyst with MRI
scanning. She is also known to have polycystic

Answer & Comments

Answer: 2- Von Hippel Lindau syndrome

The diagnosis is likely to be von Hippel Lindau
disease. There may be cerebellar
haemangioblastomas, retinal angiomas and
polycystic liver or kidneys. Ectopic
erythropoietin secretion by the
haemangioblastomas cause polycythaemia.

Retinal Angioma seen in von Hippel Lindau

syndrome

[ Q: 602 ] MRCPass - Neurology

An 80 year old man is admitted with
confusion over the last 3 days. He has a past
medical history of hypertension and has had
frequent falls in the past. Clinical examination
is unremarkable.

Which of these conditions needs to be
excluded?

1- Intracranial haemorrhage

2- Subdural haematoma

3- Meningitis

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4- Vertebrobasilar stroke

5- Encephalitis

Answer & Comments

Answer: 2- Subdural haematoma

A patient who has had a fall may have hit his
head and developed a subdural haematoma.
This can be excluded by a CT head scan.

Right sided subdural haematoma

[ Q: 603 ] MRCPass - Neurology

A 45 year old man presents with a
sudden onset of headache in the posterior
region, associated with vomiting.

Neurological examination, including
fundoscopy is unremarkable apart from
slightly brisk reflexes. There is no neck
stiffness or photophobia.

Which of the Following management options
would be the most appropriate?

1- CT of the head and lumbar puncture

2- MRI of the head

3- CT of the head

4- Skull X ray

5- Discharge from hospital

Answer & Comments

Answer: 1- CT of the head and lumbar
puncture

A subarachnoid haemorrhage (SAH) needs to
be excluded. CT brain scan is normal in a third
of patients with SAH. A lumbar puncture to
look for xanthochromia in the CSF should then
be performed.

[ Q: 604 ] MRCPass - Neurology

A 40 year old patient has presented
with a generalised tonic clonic seizure for the
first time. This lasted for 10 minutes.

What advice should be given regarding driving
a car?

1- No driving for 1 month

2- No driving for 6 months

3- No driving for 1 year

4- Driving is allowed if EEG is normal

5- Driving is allowed if CT scan is normal

Answer & Comments

Answer: 3- No driving for 1 year

For a single seizure, driving is not permitted
for 1 year. Also, a medical review is required
before one is to do so and it is a requirement
for the patient to inform the Driver and
Vehicle Licensing Authority.

[ Q: 605 ] MRCPass - Neurology

The sister of a patient who died from
a subarachnoid hemorrhage due to a cerebral
aneurysm is worried and is asking about her
chances of having the same problem. She
mentions that there family history of other
deaths from subarachnoid haemorrhage. She
is how ever, asymptomatic.

What should be done?

1- Reassure and nothing else

2- CT scan of head

3- MRI head scan

4- Cerebral angiography

5- Lumbar puncture

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Answer & Comments

Answer: 3- MRI head scan

This may be a case of familial subarachnoid
haemorrhage. In those who have a first
degree relative who genuinely suffered a SAH,
their risk of also suffering one is 3-7 times that
of the general population. MRI is better than
CT scan for screening. Angiography is
diagnostic but too invasive for screening.

[ Q: 606 ] MRCPass - Neurology

A 45 year old lady has a 4 week
history of pain and difficulty seeing out of her
right eye. She has a visual acuity of 6/18 in the
right and 6/6 in the left. There is also a right
afferent pupillary defect.

Which is the most likely cause from the list
below?

1- Thyroid eye disease

2- Diabetic retinopathy

3- Astrocytoma

4- Multiple sclerosis

5- Retinitis pigmentosa

[ Q: 607 ] MRCPass - Neurology

A 40 year old lady presents with
drooping of her eye lids and double vision. She
does not have proptosis. There is no muscle
wasting around the face. She has diplopia on
downgaze during examination and also
proximal muscle weakness of her upper limbs.
Myasthenia gravis is diagnosed.

Which drug is most likely to improve her
symptoms?

1- Beta interferon

2- Intravenous immunoglobulin

3- Benztropine

4- Pyridostigmine

5- Bromocriptine

Answer & Comments

Answer: 4- Pyridostigmine

The condition described is Mysthenia Gravis
rather than Grave's eye disease or Myotonic
dystrophy (frontal balding). Pyridostigmine is
an anticholinesterase which reduces
acetylcholine breakdown and hence improve
symptoms of fatiguability in myasthenia
gravis.

Answer & Comments

Answer: 4- Multiple sclerosis

Optic neuritis secondary to multiple sclerosis
can present in this manner.

Disc pallor (optic neuritis)

^ [ Q: 608 ] MRCPass - Neurology

-——-

# A 40 year old bank clerk presents
with a headache, nausea and ptosis of the left
eye with blurred vision. She does not have
fatiguability of her eye movements.
Examination revealed sw elling on the left side
of face, proptosis and chemosis of the left eye,
left mastoid sw elling and left
ophthalmoplegia involving cranial nerves.

The pupil sizes were equal. A CT of her head is
normal.

What is the likely diagnosis?

1- Third nerve palsy

2- Myasthenia gravis

3- Pituitary tumour

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4- Cavernous sinus thrombosis

5- Horner's syndrome

Answer & Comments

Answer: 4- Cavernous sinus thrombosis

A history of headache and no other obvious
cause of ptosis is suggestive of cavernous
sinus thrombosis. Third nerve palsy is
associated with dilated pupil and Horner's
syndrome is associated with miosis. A CT can
be normal, and diagnosis is confirmed with
MRI.

[ Q: 609 ] MRCPass - Neurology

A 65 year old man presents with an
episode of amnesia for the second time. 2
days ago he had an episode of confusion,
according to his wife. He was, how ever, able
to have a normal conversation despite having
been found wandering. After 2 hours, he
abruptly returned to normal and could not
remember what happened.

Whot is the most likely diagnosis?

1- Alcoholic encephalopathy

2- Subarachnoid haemorrhage

3- Complex partial seizure

4- Transient ischaemic attack

5- Transient global amnesia

Answer & Comments

Answer: 5- Transient global amnesia

Transient global amnesia (TGA) is a temporary
and isolated disorder of memory which may
last several hours. Heavy exercise and the cold
are known precipitants.

[ Q: 610 ] MRCPass - Neurology

A 40 year old man presents with
finger weakness which was diagnosed as an
ulnar nerve lesion.

Which of the Following muscles is supplied by
the ulnar nerve?

1- Interossei

2- Lateral two lumbricals

3- Opponens pollicis

4- Abductor pollicis brevis

5- Flexor pollicis brevis

Answer & Comments

Answer: 1- Interossei

The interossei muscles and medial two
lumbricals are supplied by the ulnar nerve.
The lateral two lumbricals (anatomical
position), opponens pollicis, abductor pollicis
brevis and flexor pollicis brevis are supplied by
the median nerve.

[ Q: 611 ] MRCPass - Neurology

A 35 year old alcoholic presents with
unsteadiness whilst walking. On examination
he has increased tone and brisk reflexes in the
right leg. Proprioception is abnormal in the
right leg. There is loss of vibration sense in the
right leg. There is decrease in pain and
temperature sensation in the left leg.

Which one of the following conditions is most
likely to be responsible for his weakness?

1- Syringomyelia

2- Subacute combined degeneration of cord

3- Friedrich's ataxia

4- Guillain Barre syndrome

5- Brown Sequard syndrome

Answer & Comments

Answer: 5- Brown Sequard syndrome

Brown Sequard syndrome which describes
hemisection of the spinal cord, causes
ipsilateral UMN signs and proprioception loss
(corticospinal tract and dorsal column
decussate at the medulla), and contralateral

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sensory loss in pain and temprature (the
spinothalamic tracts decussate at the same
level). The rest of the conditions
(syringomyelia, subacute degeneration of
cord, Friedrich's ataxia) can cause cerebellar
signs or patchy sensory loss but should be
bilateral.

Which is the most appropriate treatment?

1- Glucose

2- Lorazepam

3- IV thiamine

4- IV Vitamin B n

5- IV vitamin K

[ Q: 612 ] MRCPass - Neurology

* A 45 year old man has bilateral
ptosis. He mentions a past history of cataracts,
frontal balding and weakness of the facial
muscles. On examination, he has a firm grip
with difficulty relaxing.

What is the diagnosis?

1- Multiple sclerosis

2- Motor neuron disease

3- Parkinson's disease

4- Dermatomyositis

5- Myotonic dystrophy

Answer & Comments

Answer: 5- Myotonic dystrophy

Myotonic dystrophy is autosomal dominant. It
is a trinucleotide repeat disorder which
exhibits anticipation (worse with successive
generations). Associated features are
cataracts, diabetes, testicular atrophy and
cardiac conduction abnormalities.

Myotonic Dystrophy

[ Q: 613 ] MRCPass - Neurology

A 50 year old alcoholic is admitted to
A+E with unsteadiness and confusion. BM is 7.

Answer & Comments

Answer: 3- IV thiamine

This patient is likely to have Wernicke's
encephalopathy causing confusion. IV
thiamine should given to reduce the
progression. This is contained in Pabrinex.

[ Q: 614 ] MRCPass - Neurology

A man presents with generalised
weakness. On examination, fatiguability was
demonstrated. A diagnosis of Eaton Lambert
syndrome was made.

What form of antibody is found in this
condition?

1- Anti Purkinje

2- Anticholinesterase

3- Neuromuscular junction

4- Potassium channels

5- Voltage gated calcium channels

Answer & Comments

Answer: 5- Voltage gated calcium channels

Eaton Lambert syndrome is frequently
associated with a malignancy e.g. bronchial.
The disorder is associated with antibodies
against voltage gated calcium channels.

[ Q: 615 ] MRCPass - Neurology

A 20 year old man injured himself
whilst snow boarding. On examination, he has
weakness of elbow flexion and loss of

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sensation over the radial aspect of her
forearm.

Which of the Following nerves is damaged?

1- Musculocutaneous nerve

2- Brachioradialis nerve

3- Radial nerve

Which one of the Following needs to be
excluded?

1- Vaso vasagal syncope

2- Pseudoseizure

3- Anxiety disorder

4- Visual hallucinations

4- Median nerve

5- Ulnar nerve

Answer & Comments

Answer: 1- Musculocutaneous nerve

The fibers of the musculocutaneous nerve
originate in the lower cervical spinal cord
(usually C5 to C7), travel via the lateral cord of
the brachial plexus, and supply sensory and
motor innervation to the upper arm, elbow ,
and forearm. It supplies the biceps which
controls elbow flexion. Sensation is to the
lateral area (lateral cutaneous nerve) of the
forearm.

Musculocutaneous Nerve

formed from lateral
cord of brachial plexus

pierces coracobracliialis
then lies between biceps
and brachialis

becomes lateral cutaneous
nerve of forearm at elbow

^ [ Q: 616 ] MRCPass - Neurology

# An 18 year old woman is referred to
the GP by her teacher. The teacher was
concerned about frequent episodes of day
dreaming during class and poor examination
results over the past year.

5- Absence seizures

Answer & Comments

Answer: 5- Absence seizures

Daydreaming in children can be easily
confused with absence or complex partial
seizures, in which staring is a prominent and
common feature. However, lip smacking, eye
blinking, or stiffening of muscle groups is
common during seizures but not during
daydreaming.

[ Q: 617 ] MRCPass - Neurology

A 20 year old man presents with a 6
month history of depression and painful
sensory disturbance in both legs. He has also
become very confused. There are myoclonic
jerks observed in his legs. His MRI scan reveals
thalamic hyperintensity and EEG is normal.

The most likely diagnosis is:

1- New variant CJD

2- Huntington's disease

3- Wilson's disease

4- Progressive multifocal leucoencephalopathy

5- Paraneoplastic syndrome

Answer & Comments

Answer: 1- New variant CJD

New variant CJD commonly presents in young
adults painful sensory symptoms in the lower
limbs and also psychiatric symptoms.
Cognitive impairment, pyramidal signs,
myoclonus and primitive reflexes then
develop.

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MRI commonly shows high signal on T2-w
eighted images in the pulvinar (posterior
aspect of thalamus). EEG is often normal,
unlike sporadic CJD, in which triphasic waves
are observed.

[ Q: 618 ] MRCPass - Neurology

A 60 year old woman is admitted
with a severe headache. CT scan conforms a
subarachnoid haemorrhage. She initially
makes satisfactory progress but 7 days later
her level of consciousness begins to
deteriorate.

The most likely couse of the deterioration is:

1- Cerebral oedema

2- Coning of the medulla

3- Meningitis

4- Encephalitis

5- Acute hydrocephalus

Answer & Comments

Answer: 5- Acute hydrocephalus

Organised blood in the subarachnoid space
may cause obstruction to the flow of
cerebrospinal fluid (impaired absorption in the
arachnoid villi). 10% of patients will require
CSF diversion or shunting.

[ Q: 619 ] MRCPass - Neurology

A 62 year old woman has several
episodes of dizziness particularly when she
turns her head. 2 months ago, she had an
attack of vertigo, without deafness or tinnitus,
lasting for a few minutes. Over the last month,
she had five further attacks of vertigo,
accompanied by moderate headache and a
left homonymous hemianopia, lasting for
about a quarter of an hour. After the last
episode she developed persistent
unsteadiness of gait, and was admitted to
hospital.

On examination there was normal visual
fields, were full. There was rhythmic
horizontal nystagmus, slight weakness of the
right external rectus muscle without diplopia,
and ataxia of gait, provoked by turning. The
bloodpressure was 160/80 mmHg.

Whot is the diagnosis?

1- Parietal lobe CVA

2- Frontal lobe CVA

3- Vertebrobasilar insufficiency

4- Syringomyelia

5- Brown sequard syndrome

Answer & Comments

Answer: 3- Vertebrobasilar insufficiency

Vertebrobasilar (posterior) circulation
constitutes the arterial supply to the brain
stem, cerebellum, and occipital cortex.
Bilateral visual loss, dizziness, speech
disturbances, drop attacks and transient
global amnesia are features of vertebrobasilar
insufficiency. MRI / MRA are good
investigations to investigate for vertebral or
basilar arterial disease.

[ Q: 620 ] MRCPass - Neurology

A 55 year old man has developed
weakness over the past 3 weeks which has
affected his walking. He has no significant past
medical history. On examination, he had
decreased sensation peripherally in the legs
and also flaccid reflexes in the ankles. A CT of
the head was normal and lumbar puncture
was done.

Results were:
protein 0.75( <0.43 g/l)
glucose 4 (3.3 to 4.4 mmol/l)
lymphocytes 7 (< 5/mm 3 )
Whot is the likely diagnosis?

1- Multiple sclerosis

2- Guillain Barre syndrome

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3- Lymphocytic meningitis

4- Tuberculous meningitis

5- Syringomyelia

Answer & Comments

Answer: 2- Guillain Barre syndrome

In Guillain Barre syndrome, CSF protein is
elevated in most patients after the second or
third week of illness. The gamma globulin
fraction is usually raised. Cells, usually
monocytic, are found in 20% of cases.

[ Q: 621 ] MRCPass - Neurology

A 65 year old patient has progressive
dementia. His wife mentions that he has
urinary incontinence and an ataxic gait.

What is his CT scon likely to show ?

1- Parasagittal mass

2- Multiple infarcts

3- Large ventricles

4- Cerebellar tumour

5- Berry aneurysm

Answer & Comments

Answer: 3- Large ventricles

The diagnosis is normal pressure
hydrocephalus. Dementia, urinary
incontinence and unsteady gait are seen.
Typically there is no papilloedema. There are
large ventricles caused by communicating
hydrocephalus. Ventricular shunting may help
improve the symptoms.

Normal Pressure Hydrocephalus

[ Q: 622 ] MRCPass - Neurology

A 60 year old lady presents with
acute onset unsteadiness and dizziness.
Neurological examination shows a right-sided
Horner's syndrome and nystagmus. There is
also loss of pain and temperature sensation
on the left side of the trunk and in the left arm
and leg. Her gait is ataxic.

Which is the correct diagnosis?

1- Posterior inferior cerebellar artery
occlusion

2- Medullary infarct

3- Posterior cerebral artery occlusion

4- Middle cerebral artery occlusion

5- Posterior communicating artery
haemorrhage

Answer & Comments

Answer: 1- Posterior inferior cerebellar artery
occlusion

There are a complex of symptoms caused by
occlusion of the posterior inferior cerebellar
artery or one of its branches supplying the
lower portion of the brain stem, resulting in
sensory and sympathetic disturbances,
cerebellar and pyramidal tract signs, and
evidence of partial involvement of the fifth,
ninth, tenth, and eleventh cranial nerves.

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Onset is usually acute with severe vertigo.
Nausea, vomiting, ipsilateral ataxia, muscular
hypertonicity, pastpointing and other
cerebellar signs are often present. Horner's
syndrome is usually present. Sensory
disturbances include ipsilateral loss of pain
and temperature perception of the face and
contralateral hypoesthaesia for pain and
temperature of the trunk and extremities.

The affected persons have difficulty in
swallowing. Persons well over 40 years of age
are most often affected.

[ Q: 623 ] MRCPass - Neurology

A 60 year old man has new onset
receptive and expressive dysphasia. His past
medical history includes diabetes and
hypertension.

On examination, he has increased tone and
extensor plantar reflex on the right. He also
has weakness of the right leg with sensory loss
over the same side.

walking is even greater than expected from
the weakness present.

Dysphasia could occur with the occlusion of a
branch of the left ACA. Branch occlusion of the
ACA can cause only parts of the total
syndrome, producing a spastic weakness or
cortical sensory loss in the opposite foot and
leg.

Anterior Cerebral Artery Infarct

Which vascular lesion is likely?

1- Anterior cerebral artery

2- Superior middle cerebral artery

3- Inferior middle cerebral artery

4- Posterior cerebral artery

5- Posterior inferior cerebellar artery

Answer & Comments

Answer: 1- Anterior cerebral artery

A middle cerebral artery occlusion is likely to
cause total hemiplegia. In view of the partial
weakness, an anterior cerebral artery (ACA)
lesion is more likely.

Complete infarction due to occlusion of one
ACA distal to the anterior communicating
artery results in a sensory-motor deficit of the
opposite foot and leg and a lesser degree of
paresis of the arm with sparing of the face.
Foot drop is a common finding and difficulty in

[ Q: 624 ] MRCPass - Neurology

A 35 year old man is admitted with
acute right sided weakness and slurred
speech. He does not have a history of
hypertension, diabetes or high cholesterol.
There is no family history of CVA. He does not
smoke. He complains of headaches and
generalised limb weakness infrequently.

On examination, he has hypotonia and
weakness in the proximal muscles more than
the distal muscles. His laboratory tests show a
high lactate to pyruvate ratio.

What is the likely diagnosis?

1- Polymyositis

2- Inclusion body myositis

3- ME LAS

4- Polymorphonuclear leukoencephalopathy

5- Neuroacanthocytosis

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Answer & Comments

Answer: 3- MELAS

This patient has MELAS (myopathy,
encephalopathy, lactic acidosis and stroke like
episodes).

Lactic acidosis is a very important feature of
this disorder, as measured by a high lactate to
pyruvate ratio.

How ever, in general, lactic acidosis does not
lead to systemic metabolic acidosis, and it
may be absent in patients with impressive
involvement of the central nervous system.

Patients have a myopathy causing proximal
muscle weakness and hypotonia, seizures and
strokelike episodes. It is a mitochondrial
inherited disorder.

^ [ Q: 625 ] MRCPass - Neurology

f L -—-

m A 75 year old lady complains of a
headache for 2 days in the right side of the
head. The pain is worse when she is chewing
or talking. She has also had mild fevers and sw
eats. Her ESR is 80 mm/hr. The vision in the
right eye is 6/18 and her left eye is 6/6.

What is the best course of action?

1- Start iv methylprednisolone

2- Organise and await temporal artery biopsy

3- CT of the head to exclude space occupying
lesion

4- MRI of the brain

5- Refer to an ophthalmologist

Answer & Comments

Answer: 1- Start iv methylprednisolone

There are early signs of visual loss so high
dose steroids should be commenced with the
suspicion of temporal arteritis. Although all
the other options are reasonable, they may
take time and there should not be delay in
commencing steroids.

[ Q: 626 ] MRCPass - Neurology

A 35 year old woman presents with
double vision that is worst when trying to read
a book or walk down stairs.

The most likely diagnosis is:

1- Progressive supranuclear palsy

2- 4th nerve palsy

3- 3rd nerve palsy

4- 6th nerve palsy

5- Internuclear ophthalmoplegia.

Answer & Comments

Answer: 2- 4th nerve palsy

The superior oblique muscle is innervated by
the fourth nerve. The action is to depress the
eye and is maximally effective when the eye is
looking medially, hence diplopia on reading or
going downstairs is typical of fourth nerve
paralysis.

[ Q: 627 ] MRCPass - Neurology

A 65 year old man has muscle
weakness, particularly around the thighs and
shoulders. His CK is 2,200 U/l. EMG shows
reduced amplitude and duration of motor
units.

What is the likely diagnosis?

1- Dermatomyositis

2- Myasthenia gravis

3- Myotonic dystrophy

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4- Peripheral neuropathy

5- Multiple sclerosis

Answer & Comments

Answer: 1- Dermatomyositis

These EMG changes are consistent with a
myositis. In motor neuron disease, fibrillation
is seen. In myasthenia, there is diminished
response to repetitive stimulation.

only. The episode lasted a few seconds and he
has been relatively well. Examination reveals a
mild hemiparesis of the left arm and leg.

Which is the likely diagnosis?

1- Pontine haemorrhage

2- Primary epilepsy

3- Medullary haemorrhage

4- Right internal capsule infarct

5- Left internal capsule infarct

[ Q: 628 ] MRCPass - Neurology

A 42 year old man presents to A+E
complaining of severe lower back pain
Following carpentry work. The pain radiates to
his left buttock and thigh.

On examination, he was able to straight leg
raise to 45 degrees only on the left side. The
sciatic stretch test is positive. He has difficulty
plantar flexing his left ankle and has abnormal
sensation on the plantar aspect of the foot.

What is the diagnosis?

1- Cauda equina syndrome

2- L2/L3 disc prolapse

3- L4/L5 disc prolapse

Answer & Comments

Answer: 4- Right internal capsule infarct

This patient is likely to have a lacunar infarct
involving the internal capsule, causing
transient contralateral hemiparesis.

[ Q: 630 ] MRCPass - Neurology

A 25 year old man has had
behavioural disturbance recently. His parents
mentioned that his brother has been
investigated for liver problems recently. On
examination, he has a MMSE score of 28/30.
He has a mask like face and was noticed to
have hypersalivation.

4- L5/S1 disc prolapse

5- Common peroneal nerve injury

Answer & Comments

Answer: 4- L5/S1 disc prolapse

Ankle dorsiflexion is generally supplied by
L4/L5 and plantar flexion supplied by S1/S2.

When investigations are complete, which drug
is most likely to be used for treatment?

1- Desferrioxamine

2- Co careldopa

3- Penicillamine

4- Interferon alpha

5- Chlorpromazine

this case is likely to be due to sciatic nerve
palsy.

[ Q: 629 ] MRCPass - Neurology

A 60 year old man is brought to
hospital having collapsed to the ground
suddenly and was unable to move his left leg
or arm. There was no loss of consciousness.
He has a past medical history of hypertension

Answer & Comments

Answer: 3- Penicillamine

The likely diagnosis is Wilson's disease. Most
patients who present with neuropsychiatric
manifestations have cirrhosis. The most
common presenting neurologic feature is
asymmetric tremor, occurring in
approximately half of individuals with Wilson

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disease. Frequent early symptoms include
difficulty speaking, excessive salivation, ataxia,
masklike facies, clumsiness with the hands,
and personality changes. The disease is
autosomal recessive. Penicillamine is used as a
copper chelator.

[ Q: 631 ] MRCPass - Neurology

A 55 year old man presents with a
history of slowly progressive, abnormal
movements of his body. On examination there
are jerky, semi-purposive movements
involving the entire body and abnormal
tongue movements.

What is the likely diagnosis?

1- Parkinson's disease

2- Motor neuron disease

3- Frontal lobe tumour

4- Cervical spondylosis

5- Huntington's disease

described as "explosive" and were graded 9 to
10 in severity on a visual analog scale of 1 to
10.

The quality of the head pain was reported to
be throbbing, sharp, shooting, as well as
aching. The pain was localized around the
right eye, behind the right ear, and in the
occipital region. There are no associated visual
symptoms, but occasionally flushing is
associated. He gets these headaches
frequently during the winter.

What is the likely diagnosis?

1- Migraine

2- Trigeminal neuralgia

3- Absence seizures

4- Sagittal sinus thrombosis

5- Cluster headache

Answer & Comments

Answer: 5- Cluster headache

Answer & Comments

Answer: 5- Huntington's disease

There are many causes of chorea.

Inherited- Ataxia-telangiectasia, Huntington
disease, Wilson disease.

In cluster headaches, there is an association
with autonomic features, particularly miosis
and ptosis. Cluster headaches occur during the
same months in the year typically and are
almost five times more common in males. A
opthalmic division of trigeminal nerve
distribution involvement is also common.

Drugs - Anticonvulsants (eg, phenytoin,
carbamazepine, phenobarbital),

Antidopaminergic agents (eg, phenothiazines,
haloperidol, metoclopramide)

Behget disease, antiphospholipid antibody
syndrome, Bacterial endocarditis, Herpes
simplex encephalitis, Lyme disease.

[ Q: 632 ] MRCPass - Neurology

A 40 year old man has a 5-year
history of right-sided cluster headaches with
recurrent right sided headaches which last for
2 hours. There is a pattern of daily occurrence
for 2 to 3 weeks, followed by a month or so
without headaches. The headaches were

[ Q: 633 ] MRCPass - Neurology

A 30 year old man complains of
spasms in his neck. He has, over the past three
years, noticed a crampy sensation in his neck
associated with contraction of the muscle on
the left. This has now got frequent and
uncontrollable. Neurological examination is
normal, but on tapping the left side of the
neck muscle, it contracts and spasms occur.

Which of the Following medication may help
this?

1- Methysergide

2- Levodopa

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3- Phenytoin

4- Lamotrigine

5- Methyldopa

Answer & Comments

Answer: 2- Levodopa

This patient has a dystonia in the neck. Other
examples are blepharospasm and torticollis.

This could be helped by levodopa or
diazepam. In severe cases, botulinum
injections may also help.

[ Q: 635 ] MRCPass - Neurology

A 30 year old man has a painful right
eye. On examination, there is decreased visual
acuity and a relative afferent pupillary defect
of the right eye.

What is the diagnosis?

1- Optic atrophy

2- Optic neuritis

3- Glaucoma

4- Retinitis pigmentosa

5- Internuclear opthalmoplegia

[ Q: 634 ] MRCPass - Neurology

Answer & Comments

•U

A 45 year old man was referred for

Answer: 2- Optic neuritis

assessment of unsteady gait, which has been
present for 6 months. He has lost a stone in
weight over the several months. An MRI of the
brain shows multiple high signal areas.

A painful eye with loss of vision, and also
RAPD suggests optic neuritis. The most likely
underlying cause is multiple sclerosis.

A biopsy was taken of one of the lesions. The
report shows perivascular infiltrates of
lymphocytes affecting white and gray matter.
There was minimal myelin loss. CSF
examination shows raised white cell count,
and oligoclonal bands were not raised.

What is the most likely diagnosis?

1- Creutzfeldt Jakob disease

2- Progressive multifocal leucoencephalopathy

3- CNS lymphoma

4- Glioma

5- HSV encephalitis

[ Q: 636 ] MRCPass - Neurology

A 50 year old man has developed
unsteadiness. He has hypertension and is a
smoker of 20/day. On examination he has a
cerebellar ataxia and pass pointing. His CXR
shows a right hilar mass.

Which of the Following is most likely to reveal
the diagnosis?

1- Anti GM1 antibodies

2- Anti Yo antibodies

3- Phytanic acid levels

4- Serum copper

Answer & Comments

Answer: 3- CNS lymphoma

The white matter lesions suggest either
multiple sclerosis or lymphoma. Infiltration
with lymphocytes in this type of presentation
makes a primary lymphoma of the central
nervous system likely.

5- Serum ferritin

Answer & Comments

Answer: 2- Anti Yo antibodies

The most likely diagnosis is a paraneoplastic
syndrome. Anti Yo antibodies are found in
around half of all patients with paraneoplastic
cerebellar degeneration. Associated with small
cell carcinoma, ovarian tumours and Hodgkin's

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lymphoma. Anti Hu antibodies are associated
with small cell carcinoma of the lung. It is
usually associated with sensory neuropathy or
with encephalomyelitis.

[ Q: 637 ] MRCPass - Neurology

A 65 year old man has early signs of
cognitive impairment. His wife describes
urinary incontinence and unsteadiness on
walking in the past six months. Examination
reveals ataxia and he has an MTS score of
7/10.

[ Q: 638 ] MRCPass - Neurology

A 40 year old man has a 4 week
history of dizziness, and vomitting. The onset
was acute. He feels that the world was
spinning and his balance is poor. His hearing is
normal. There is no familiy history. On
examination, he has no cerebellar signs.

Whot is the most likely diagnosis?

1- Benign positional vertigo

2- Friedrich's ataxia

3- Acoustic neuroma

What is the most likely diagnosis?

4- Vestibular neuronitis

1- Lewy body disease

2- Alzheimer's dementia

3- Creutzfeldt jakob disease

4- Normal pressure hydrocephalus

5- Vertebro basilar circulation insufficiency

Answer & Comments

Answer: 4- Vestibular neuronitis

5- Shy drager syndrome

Answer & Comments

Answer: 4- Normal pressure hydrocephalus

Normal pressure hydrocephalus (NPH) is a
clinical symptom complex characterized by
abnormal gait, urinary incontinence, and
dementia. Ventricular enlargement occurs out
of proportion on the CT scan. Surgical CSF
shunting remains the main treatment
modality.

Vestibular neuronitis often presents with
acute vestibular disturbance that gradually
resolves over a few weeks. It is associated
with viral infections. Treatment is conservative
and supportive.

[ Q: 639 ] MRCPass - Neurology

A 62 year old man complains of
headache and on examination of his visual
fields you detect a right upper quadrantopia.

Where is the lesion?

1- Optic chiasm

2- Right temporal lobe

3- Right parietal lobe

4- Left parietal lobe

5- Left temporal lobe

Answer & Comments

Answer: 5- Left temporal lobe

Upper quadrantopia is due to temporal lobe
lesions and lower quadrantopia to parietal
lobe lesions. The visual field is caused by the
contralateral lesion.

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^ [ Q: 640 ] MRCPass - Neurology

tl -

# A 65 year old man presents with
muscle weakness and difficulty swallowing. On
examination, he has proximal and distal upper
and lower limb weakness. There is wasting of
the intrinsic muscles of the fingers and of his
thigh muscles. CK is elevated and EMG
findings are consistent with a myopathic
process.

Which condition is likely?

1- Polymyositis

2- Dermatomyositis

3- Inclusion body myositis

4- Motor neuron disease

5- Duchenne muscular dystrophy

associated with nauusea. She mentions a
blackout a few weeks prior to admission.

On examination of the patient's fundus, the
optic cups were filled and the medial margins
of the discs were blurred.

Which is the most likely cause of this patient's
condition?

1- Cerebellar tumour

2- Frontal lobe tumour

3- Temporal lobe epilepsy

4- Benign intracranial hypertension

5- Migraine

Answer & Comments

Answer: 2- Frontal lobe tumour

Answer & Comments

Answer: 3- Inclusion body myositis

The distribution of the muscles involved are
typical of inclusion body myositis, although
the distribution is usually asymmetric. In this
condition, dysphagia and respiratory
involvement can also occur. Muscle biopsy
shows intracellular inclusions (amyloid
precursor protein, ubiquitins) and
inflammatory infiltrates.

[ Q: 641 ] MRCPass - Neurology

A 65 year old female is admitted
history of severe headaches. The
headaches are worse in the morning and are

with a

The history of headaches which are worse in
the morning and accompanied by nausea
suggests increased intracranial pressure. This
is confirmed by the fact the optic discs have
blurred margins. The history of a probable
seizure with collapse, in combination with all
the other factors suggests a likely frontal lobe
tumour.

Frontal Lobe Tumour

[ Q: 642 ] MRCPass - Neurology

# A 40 year old woman presents with
gradual onset severe headache and visual
blurring. On examination, she has bilateral
papilloedema.

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Which of the Following may help improve the
condition?

1- Vitamin A

2- Prednisolone

3- Minocycline

4- Cyclosporin

5- Acetazolamide

Answer & Comments

Answer: 5- Acetazolamide

Vitamin A, prednisolone, minocycline and
cyclosporin make idiopathic intracranial
hypertension (used to be known as benign
intracranial hypertension worse.

Acetazolamide is used to treat IIH. IIH is likely
to be due to high pressure caused by the
buildup or poor absorption of cerebrospinal
fluid in the subarachnoid space surrounding
the brain. The disorder is most common in
women between the ages of 20 and 50.
Symptoms include headache, nausea,
vomiting, and pulsating intracranial noises,
closely mimicking symptoms of brain tumors.

[ Q: 643 ] MRCPass - Neurology

A 35 year old woman has been
admitted to hospital for investigation of
progressive weakness in her legs. For the past
5 years. The patient's mother has similar
difficulties with weakness and sensory
problems.

Examination revealed power of 3/5 distally in
the upper and lower limbs with a glove and
stocking pattern sensory loss to pain and
touch.

What is the likely diagnosis?

1- Hereditary neuropathy with liability to
pressure palsies

2- Friedrich's ataxia

3- Chronic inflammatory demyelinating
polyneuropathy

4- Multiple sclerosis

5- Hereditary sensori motor neuropathy

Answer & Comments

Answer: 5- Hereditary sensori motor

neuropathy

In view of the family history, this patient is
most likely to have hereditary sensori motor
neuropathy type I (Charcot Marie Tooth
disease).

HMSN 1 is the most common form of
hereditary neuropathy. Severely and
uniformly slowed nerve conduction velocities
(NCVs) and primary hypertrophic myelin
pathology with prominent onion bulbs and
secondary axonal changes are the hallmarks of
the disease. Motor symptoms predominate
over sensory symptoms. Often, patients
report loss of balance, muscle weakness, and
foot deformities. Onset in the first decade of
life is typical, but disease develops in some
patients in young or mid adulthood.

HMSN 2, on the other hand, represents the
nondemyelinating neuronal type with
relatively normal NCVs and primary axonal
pathology. Although nerves are not enlarged
in the neuronal form, weakness often is less
marked and onset of this neuropathy is
delayed. Peripheral nerves are not enlarged
clinically, and weakness of feet and leg
muscles predominates; hands are less severely
affected than the legs. Patients experience
sensory loss in the distal extremities, and foot
deformities (ie, pes cavus) tend to be less
marked than those of HMSN 1.

[ Q: 644 ] MRCPass - Neurology

An 80 year old lady is admitted
complaining of acute onset weakness in both
legs and low back pain for the previous 4
weeks. She has lost 5 kg of weight recently,
and has a Hb of 8.5 g/dl. Her cranial nerves
and upper limbs were normal but she has
reduced power in both lower limbs of 3/5. She

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has a sensory level at T12 and plantar reflexes
are upgoing. Rectal tone was normal.

Which is the best next investigation?

1- Bone scan

2- CT scan of the abdomen

3- MRI scan of the spine

4- CT scan of the brain

5- MRI of the brain

Answer & Comments

Answer: 3- MRI scan of the spine

This patient is likely to have cord compression
from a metastases to the spine.

Urgent MRI scan is required to confirm the
diagnosis and a referral for either surgery or
radiotherapy can then be made.

choreiform movements and cognitive
impairment. Cerebellar signs are more typical
in Friedrich's ataxia.

[ Q: 646 ] MRCPass - Neurology

A 60 year old man develops
swallowing difficulties and complains of
difficulty walking up stairs.

On examination, there is weakness and
wasting of the distal muscles of the arms.
There are visible fasciculations. Reflexes are
brisk and the plantars are upgoing. There are
no sensory abnormalities. Speech and
language assessment suggests the presence of
pharyngeal muscle weakness.

What is the most likely diagnosis?

1- Guillain Barre

2- Motor neuron disease

[ Q: 645 ] MRCPass - Neurology

A 30 year old man had a progressive
four month history of stiffness, tremors and
unsteadiness. There is no family history of a
similar problem.

On examination, there is globally increased
tone. Power is normal and there are brisk
reflexes throughout. A resting tremor and
some abnormal writhing movements in the
arms were observed. He has an MMSE score
of 25/30.

What is the most likely diagnosis?

1- Motor neuron disease

2- Polymyalgia rheumatica

3- Friedrich's ataxia

4- Wilson's disease

5- Temporal arteritis

Answer & Comments

Answer: 4- Wilson's disease

Neuroacanthocytosis, Wilson's, Huntington's,
paraneoplastic syndrome can present with

3- Myasthenia gravis

4- Chronic inflammatory demyelinating
polyneuropathy

5- Paraneoplastic syndrome

Answer & Comments

Answer: 2- Motor neuron disease

This is a classical presentation of motor
neuron disease. There is a pseudobulbar palsy
in association with fasciculations of the
muscles and a mixture of upper and lower
motor neuron signs.

[ Q: 647 ] MRCPass - Neurology

A 35-year-old female was admitted
to the hospital after experiencing a sudden
and severe episode of headache.

No precipitating factor was identified. Except
for mild neck stiffness, general physical and
neurological examinations were

unremarkable.

On admission, computed tomography (CT)
scan showed a thin collection of blood on the

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right sylvian cistern, establishing the diagnosis
of subarachnoid haemorrhage.

The admitting doctor is considering further
management.

Which of the Following medications have been
shown to decrease the incidence of cerebral
infarction in patients with subarachnoid
haemorrhage?

1- Amlodipine

2- Prednisolone

3- Nimodipine

4- Acetazolamide

5- Bendrofluazide

Answer & Comments

Answer: 3- Nimodipine

Nimodipine (calcium channel blocker) has
been shown to improve outcome in patients
with subarachnoid haemorrhage. It is given
60mg orally, 4-hourly.

[ Q: 648 ] MRCPass - Neurology

A 28 year old woman is assessed for
easy fatigue. She complains of weakness of
her hands causing poor coordination and
double vision. This is worst in the evenings.

What is the diagnosis?

1- Guillain barre syndrome

2- Multiple sclerosis

3- Myasthenia gravis

4- Paraneoplastic syndrome

5- Central pontine myelinolysis

Answer & Comments

Answer: 3- Myasthenia gravis

Myasthenia gravis is an acquired autoimmune
disorder characterised by weakness, typically
of the periocular, facial, bulbar, and girdle
muscles. Diplopia, ptosis and slurring of the

speech are common symptoms. There is
typically fatiguabulity on examination, and
symptoms are worse during the evenings. It is
associated with serum IgG antibodies to
acetylcholine receptors in the postsynaptic
membrane of the neuromuscular junction.

[ Q: 649 ] MRCPass - Neurology

A 35 year old lady has developed
progressive weakness in the hands and feet
over a week. There is some associated
numbness and tingling in the hands and feet.
She complains of breathing difficulty. She had
several episodes of diarrhoea two weeks ago.

On examination, there is slurring of speech.
Her reflexes are all absent and there is sensory
loss in a glove and stocking pattern.

Which is the next appropriate step?

1- MRI

2- Lumbar puncture

3- Vital capacity

4- EMG

5- Anti Ach antibody

Answer & Comments

Answer: 3- Vital capacity

Guillain Barre syndrome is the likely diagnosis.
As she is complaining of breathlessness, vital
capacity measurement would be essential
because of potential rapid deterioration in
respiratory function.

[ Q: 650 ] MRCPass - Neurology

A 40 year old patient has been
diagnosed with migraine recently. The
migraines seem to have increased in
frequency since being on a triptan.

What is the next medication to use?

1- Propanolol

2- Tramadol

3- Carbamazepine

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4- Neurofen

5- Aspirin

Answer & Comments

Answer: 1- Propanolol

In migraines, beta blockers, calcium channel
blockers and antidepressants may be helpful
in prophylaxis.

Broca

Wernicke

Left Side View

[ Q: 651 ] MRCPass - Neurology

A 50 year old man presents with
speech difficulty. He has difficulty with word
identification and repetition. He is able to pick
out correct objects when instructed to do so
and is not confused.

Where is the lesion?

[ Q: 652 ] MRCPass - Neurology

A 60 year old man has presented
with an episode of transient visual loss lasting
for 5 minutes. He maintained consciousness
throughout. A CT scan did not show any
changes. He mentions that he is driving
currently.

1- Superior frontal lobe

2- Parietal lobe

3- Medial superior temporal lobe

4- Posterior, superior temporal lobe
(Wernicke's area)

5- Inferior frontal lobe (Broca's area)

Answer & Comments

Answer: 5- Inferior frontal lobe (Broca's area)

Broca's Area (Inferior frontal lobe) damage
causes impaired fluency, intact
comprehension, impaired repetition
[expressive dysphasia].

Wernicke's Area (posterior, superior temporal
lobe) damage causes normal fluency, impaired
comprehension, impaired repetition
[receptive dysphasia].

How long is a patient required to avoid driving
a car Following recovery from a single
transient ischaemic attack?

1- 6 weeks

2- 1 month

3- 3 months

4- 6 months

5- 1 year

Answer & Comments

Answer: 2-1 month

Following a TIA, a patient should not drive for
1 month. If there were recurrent TIAs, then
the patient should be symptom free for 3
months before driving.

Following a seizure with altered conscious
level, a patient should not drive for 1 year. All
cases should be reported to the Driver Vehicle
Licensing Agency (DVLA).

[ Q: 653 ] MRCPass - Neurology

A 40 year old man complained of
severe headache. Following this, he then
developed nausea and vomiting and came to

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A+E to be assessed. A CT scan demonstrated
blood in the left sylvian fissure.

Abductors (DAB) and Palmar: Adductors
(PAD).

Which of the Following is the most likely
couse?

1- Migraine

2- Subdural haematoma

3- Sagittal sinus thrombosis

4- Carotid dissection

5- Berry aneurysm rupture

Answer & Comments

Answer: 5- Berry aneurysm rupture

The history is consistent with a subarachnoid
haemorrhage, caused by rupture of a berry
(saccular) aneurysm.

[ Q: 654 ] MRCPass - Neurology

A 46 year old man had suffered from
classical seropositive rheumatoid arthritis for
10 years. He has never received treatment
with phenylbutazone, gold, or antimalarials.
intense pain in the right hand. Over a course
of 3 weeks, he noticed pain, numbness, and
tingling on the lateral aspect of the palm and
in the fourth and fifth fingers of the right
hand. On examination, he has weakness in the
abductors and adductors of the fingers, and
his hand is held in a clawed position.

Whot is the diagnosis?

1- Common peroneal nerve lesion

2- Lateral cutaneous nerve lesion

3- Radial nerve lesion

4- Median nerve lesion

5- Ulnar nerve lesion

A lesion in the anterior interosseous nerve
results in weakness of the terminal phalanges
of the thumb and index fingers.

Claw Hand

[ Q: 655 ] MRCPass - Neurology

A 65 year old man has recently been
involved in an accident. On examination, there
was increased tone in the right leg, he had
right sided leg weakness and loss of
proprioception on the right side of the lower
limb. There was also left sided loss of
sensation to pain on the left leg.

Whot is the diagnosis?

1- Myalgic encephalitis

2- Motor neuron disease

3- Brown Sequard syndrome

4- Creutzfeldt Jakob disease

5- Subacute combined degeneration
syndrome

Answer & Comments

Answer: 3- Brown Sequard syndrome

Answer & Comments

Answer: 5- Ulnar nerve lesion

The ulnar nerve supplies the lumbricals (claw
hand) and also the Interossei- Dorsal:

Brown Sequard or hemisection of the spinal
cord causes in loss of sensation to pain and
temperature contralateral to the lesion, with
ipsilateral loss of sensation for position and
vibration, and upper motor neuron paralysis
ipsilateral to the lesion.

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[ Q: 656 ] MRCPass - Neurology

A 38 year old lady has difficulty
walking. On examination, she has an ataxic
gait, increased tone in the legs with
hyperreflexia and motor weakness.

What diagnostic investigation should be
arranged?

1- CT scan of the brain and spine

2- MRI of brain and spine

3- Lumbar spine X ray

4- EMG

5- EEG

Answer & Comments

Answer: 2- MRI of brain and spine

The diagnosis is likely to be multiple sclerosis.
MRI would be useful to assess for
demyelinating lesions. Following this lumbar
puncture is also helpful to confirm the
presence of oligoclonal bands (when
compared to serum).

^ [ Q: 657 ] MRCPass - Neurology

/i -

A 18 year old man has difficulty in
walking. He has had problems with vision
which were difficult to correct with glasses.

On examination, there is nystagmus and pallor
of the optic discs. He has a dysarthria and
intention tremor. There are absent reflexes in
the knees and ankles. Plantars are equivocal.
Pes cavus was noted.

What is the most likely diagnosis?

1- Spinocerebellar ataxia

2- Friedrich's ataxia

3- Alcoholic cerebellar degeneration

4- Wilson's disease

5- Hereditary sensorimotor neuropathy

Answer & Comments

Answer: 2- Friedrich's ataxia

Friedrich's Ataxia is an autosomal recessively
inherited. Patients may have cardiomyopathy
and diabetes. Neurological abnormalities
include optic atrophy and retinitis pigmentosa,
nystagmus, cerebellar disease and signs, loss
of dorsal column sensation and weakness. Pes
cavus (high arched feet) is usually present.

Pes Cavus

[ Q: 658 ] MRCPass - Neurology

A 65 year old man has been
admitted Following an episode of confusion.
He was on two different diuretic drugs on
admission which were discontinued due to
hyponatraemia. On day 1, he had a sodium of
112 mmol/l and on day 3 he had a sodium of
145 mmol/. He had developed by day 3,
spastic quadriparesis and pseudobulbar palsy.

What is the likely diagnosis?

1- Multiple sclerosis

2- Tuberculous meningitis

3- Motor neuron disease

4- Central pontine myelinolysis

5- Glioma

Answer & Comments

Answer: 4- Central pontine myelinolysis

The upper motor neuron features and rapid
correction of hyponatraemia suggests central

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pontine myelinolysis. The neurological
features may improve gradually but certain
patients have permanent neurological deficits
from rapid changes in serum sodium.

[ Q: 659 ] MRCPass - Neurology

A 40 year old man complains of pain
in the right eye, which had worsened over the
last few days.

On examination, he had a ptosis of right eye.
He also had weakness of superior upgaze of
the right eye and loss of accommodation
reflex.

Which of the Following is likely?

1- Myasthenia gravis

2- Neurosyphilis

3- Multiple sclerosis

4- Posterior communicating artery aneurysm

5- Myotonic dystrophy

Answer & Comments

Answer: 4- Posterior communicating artery
aneurysm

Patients with painful, isolated third nerve
palsy with pupillary involvement is most likely
due to a posterior communicating artery
aneurysm. Other causes of mononeuritis
multiplex (diabetes, vasculitis, syphilis), can
also cause a third nerve palsy, but seldom are
painful.

Arteriogram - Lateral view showing a posterior
communicating artery aneurysm.

^ [ Q: 660 ] MRCPass - Neurology

# A 55 year old man who was a heavy
smoker in the past complains of arm
weakness. On examination, there was postural
hypotension. He has proximal muscle
weakness with fatiguability and loss of tendon
reflexes.

Whot is the likely diagnosis?

1- Motor neuron disease

2- Myasthenia gravis

3- Transverse myelitis

4- Guillain Barre syndrome

5- Lambert Eaton myasthenic syndrome

Answer & Comments

Answer: 5- Lambert Eaton myasthenic
syndrome

In Lambert Eaton myasthenic syndrome, 60%
of cases are paraneoplastic (small cell lung ca
is most associated). The clinical features are
proximal weakness, loss of tendon reflexes
and autonomic dysfunction.

[ Q: 661 ] MRCPass - Neurology

A 60 year old man has a right wrist
drop. On examination he has an absent triceps
jerk on the right as well as an area of sensory
loss over the dorsum of the middle finger on
the right hand.

Where is the lesion?

1- Median nerve

2- Radial nerve

3- Brachial nerve

4- Ulnar nerve

5- Musculocutaneous nerve

Answer & Comments

Answer: 2- Radial nerve

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Radial nerve dysfunction involves impaired
movement or sensation of the back of the arm
(triceps), the forearm, or the hand caused by
damage to the radial nerve. There is weakness
of wrist and elbow extension, and absent
triceps jerk.

Wrist Drop

[ Q: 662 ] MRCPass - Neurology

A 24 year old tennis player find that
he is unable to extend his right wrist. On
examination, there is weakness of the
extensors of the wrist and digits.

Which of the Following structures is damaged?

1- Radial nerve

Radial Nerve Palsy

[ Q: 663 ] MRCPass - Neurology

A 50 year old lady has a painful
cheek (maxillary area) when chewing. The
neurologist diagnoses trigeminal neuralgia.

Which is the best medication to try?

1- Benztropine

2- Tramadol

3- Diclofenac

4- Propanolol

5- Carbamazepine

Answer & Comments

Answer: 5- Carbamazepine

2- Musculocutaneous nerve

3- Median nerve

4- Medial cord of the brachial plexus

5- Lateral cord of the brachial plexus

Answer & Comments

Answer: 1- Radial nerve

For trigeminal neuralgia, carbamazepine is the
first treatment of choice, but baclofen can also
be tried.

[ Q: 664 ] MRCPass - Neurology

A 46 year old woman complains of
diplopia. On examination, she has double
vision on looking to the left only.

The radial nerve may be damaged anyw here
in its course. It is most commonly affected in
the upper arm where it winds round the
humerus and in the extensor muscle
compartment of the forearm affecting the
posterior interosseous branch. Radial nerve
palsy causes weakness of the wrist and elbow
extension, and weakness of forearm
supination. Sensory loss on the dorsum of
hand and forearm may also be present.

There is failure of adduction in the right eye,
and nystagmus in the left eye whilst looking to
the left.

Which one of the Following is likely?

1- Superior rectus palsy

2- Inferior rectus palsy

3- Lateral rectus palsy

4- Medial longitudinal fasciculus defect

5- Inferior cerebellar peduncle lesion

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Answer & Comments

Answer: 4- Medial longitudinal fasciculus
defect

Diplopia on eye abduction is likely to be due to
either a lateral rectus palsy or medial
longitudinal fasciculus (MLF) defect. This
scenario fits one of internuclear
opthalmoplegia (which is due to an MLF
defect). In this scenario it is a right sided INO
same side as the eye which fails to adduct.

Internuclear opthalmoplegia

[ Q: 665 ] MRCPass - Neurology

A 35 year old patient with HIV is
assessed for new onset right arm weakness.
An MRI scan of his head shows a temporo¬
parietal ring enhancing lesion.

Which is the most likely couse for this?

1- Lymphoma

2- Toxoplasmosis

3- Behcet's disease

4- CMV

5- HSV

Cerebral Toxoplasmosis

[ Q: 666 ] MRCPass - Neurology

A 45 year old lady is with a sudden
onset of severe headache. It came on with a
'bang'. A CT scan of the brain is reported as
normal. There are no neurological signs on
examination.

The next best management step is to:

1- Start ergotamine

2- MRI of the brain

3- Perform a lumbar puncture immediately

4- Perform a lumbar puncture 24 hours after
the onset of headache

5- Repeat CT scan 24 hours later

Answer & Comments

Answer: 2- Toxoplasmosis

Cerebral toxoplasmosis is the most common
cause of a ring enhancing lesion causing
neurological defect in a HIV patient.

Answer & Comments

Answer: 4- Perform a lumbar puncture 24
hours after the onset of headache

Lumbar puncture should be performed in
suspected SAH (ideally after 24 hours from
onset of headache) if the CT scan is not
diagnostic. The CSF specimen should be
examined by spectrophotometry for the
presence of xanthochromia due to the
presence of oxyhaemoglobin and bilirubin.

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[ Q: 667 ] MRCPass - Neurology

A 40 year old man was injured in a
road traffic accident. On examination, he is
unable to extend his right hand at the wrist.
The triceps jerk is diminished, and there is
weakness of wrist flexion. A small area of over
the right middle finger has sensory loss to pain
and touch.

Answer & Comments

Answer: 3- 3rd nerve palsy

Pilocarpine is a miotic, and all the rest are
causes of small pupils as well. Although there
is no mention of ptosis or oculomotor nerve
palsy, this is the only answ er which fits with a
fixed dilated pupil

Where is the lesion?

1- Radial nerve

2- Ulnar nerve

3- C5 root

4- C7 root

5- T1 root

Answer & Comments

Answer: 4- C7 root

A C5 root lesion causes weakness in abduction
of the shoulder and biceps, as well as sensory
loss in the upper arm. A C7 root lesion causes
weak wrist extensors and flexors, weak finger
extensors and sensory loss to middle finger. A
radial nerve lesion would not involve finger
flexors. A T1 lesion would cause w eak intrinsic
hand muscles.

[ Q: 668 ] MRCPass - Neurology

A 62 year old woman presents with
diplopia. On examination, she has a fixed
dilated pupil on the right side. Direct light
reflex and accommodation reflex are totally
absent.

[ Q: 669 ] MRCPass - Neurology

A 60 year old man has previously
diagnosed with pernicious anaemia. He was
non compliant with medication for several
years. He now has unsteadiness and difficulty
walking.

Which of the Following lesions is likely?

1- Corpus callosum

2- Spinothalamic tract

3- Dorsal columns

4- Thalamus

5- Basal ganglia

Answer & Comments

Answer: 3- Dorsal columns

The diagnosis is Subacute Combined
Degeneration of the cord. The posterior
columns and corticospinal tracts are
specifically damaged, but the clinical picture is
complicated by the early development of
coexistent peripheral nerve damage.

Which one of the Following is most likely?

1- Argyll Robertson pupil

2- Horner's syndrome

3- 3rd nerve palsy

4- Pilocarpine

5- Uveitis

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Lateral

sp*nothaiamfC tract
(pam. temperature)

Posterior column
(touch, pressure,
vibration. |omt position)

Gracite Cuneate
fasciculus fasciculus

Anterior spmotfiatamic tract
(touch, pressure)

1- L2

2- L3

3- L4

4- L5

5- SI

Answer & Comments

Answer: 3- L4

In contrast, L5 lesion can cause pain radiating
through the buttock, down the postero lateral
aspect of the thigh, lateral aspect of calf and
across the dorsum of the foot.

[ Q: 670 ] MRCPass - Neurology

A 25 year old lady presents with two
month's history of episodic visual loss
affecting the right eye. Over the last two
years, she had gained a considerable amount
of weight. Examination showed bilateral optic
disc swelling and small retinal haemorrhages
in the right eye.

Which diagnosis is likely?

1- Multiple sclerosis

2- Grave's opthalmopathy

3- Retinitis pigmentosa

4- Benign intracranial hypertension

5- Kearn Sayre's disease

Answer & Comments

Answer: 4- Benign intracranial hypertension

[ Q: 672 ] MRCPass - Neurology

A 21 year old man presents with a
fever and headache. His temperature persists
and he now complains of a bad headache. He
is disorientated in casualty where he is
assessed. During examination, he has a
generalized seizure. A CT scan is performed
and it is normal. CSF examination shows a
protein of 0.3g and 10 white cells,
predominantly lymphocytes. An EEG showed
periodic sharp wave activity.

What is the most likely diagnosis?

1- Meningococcal meningitis

2- TB meningitis

3- HSV encephalitis

4- Progressive multifocal leucoencephalopathy

5- Listeria meningitis

A high BMI is associated with BIH. The
condition can be worsened by tetracycline and
oral contraceptive pills.

Answer & Comments

Answer: 3- HSV encephalitis

[ Q: 671 ] MRCPass - Neurology

A 60 year old lady presents with back
pain that radiates to the knee and down the
medial side of the calf towards the medial
malleolus.

Which nerve root is affected?

HSV encephalitis is the most likely - there can
be disorientation or dysphasia and seizures.
There is also mild lymphocytosis on the CSF. In
HSV encephalitis, MRI may show frontal or
temporal lobe involvement. EEG may show
periodic sharp wave activity temporally and
background of focal or diffuse slow ing.

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Right temporal lobe involvement in HSV

encephalitis

[ Q: 673 ] MRCPass - Neurology

A 65 year old man is assessed on the
ward for weakness in his legs. He is an ex
smoker and drinks 15 units of alcohol in a
week. His wife mentions that he is confused.
On examination, his MMSE score is 20/30. He
has an ataxic gait. There is bilateral pyramidal
weakness and coordination is impaired.
Routine blood tests are normal. An MRI scan
of the head shows diffuse white matter
changes, more in the cerebellar region than
the cerebrum.

Which of these tests would help most in
confirming the diagnosis?

1- CSF for oligoclonal bands

2- CSF for anti Hu and anti Yo antibodies

3- CSF for TB culture

of late presentation and is not commonly
associated with dementia.

[ Q: 674 ] MRCPass - Neurology

A 45 year old lady has numbness in
the right little finger and aspect of the palm
shown in the picture. The small muscles of the
hand are weak.

Which nerve is affected?

1- Median nerve

2- Radial nerve

3- Ulnar nerve

4- Anterior interosseous nerve

5- Posterior interosseous nerve

Answer & Comments

Answer: 3- Ulnar nerve

The ulnar nerve innervates the third and
fourth lumbricals, the interossei and adductor
pollicis. Sensation is supplied to the fifth finger
and the ulnar part of the fourth finger.

4- EEG

5- EMG

Answer & Comments

Answer: 2- CSF for anti Hu and anti Yo
antibodies

Anti Hu and anti Yo antibodies would help
confirm a diagnosis of paraneoplastic
syndrome. Multiple sclerosis is unlikely in view

[ Q: 675 ] MRCPass - Neurology

A 35 year old man has bradykinesia
and rigidity of his limb movements. He was
also noticed to have choreiform movements
when observed. He has a history of poor
development during the latter part of school
education.

What is the most likely diagnosis?

1- New variant CJD

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2- Parkinson's disease

3- Alzhheimer's disease

4- Normal pressure hydrocephalus

5- Huntington's disease

Answer & Comments

Answer: 5- Huntington's disease

In Huntington's disease, as the disease
progresses, chorea coexists with and gradually
is replaced by dystonia and parkinsonian
features, such as bradykinesia, rigidity, and
postural instability. It is also associated with
cognitive impairment as well as psychiatric
manifestations.

^ [ Q: 676 ] MRCPass - Neurology

# A 65 year old man has had a 6 month
history of progressive worsening of confusion.
He had left the cooker on several times and
accused the neighbours of spying on him.

On examination, his face is expressionless and
he has a monotonous speech. Cranial nerve
are normal.

Increased tone is present in all 4 limbs.
Reflexes, power and sensation are all normal.

What is the most likely diagnosis?

1- Parkinson's disease

2- Lewy body dementia

3- Alzheimer's dementia

4- Huntington's chorea

5- Creutzfeldt Jakob disease

Answer & Comments

Answer: 2- Lewy body dementia

[ Q: 677 ] MRCPass - Neurology

A 74 year old lady lives alone and is
self caring. She has home help twice a week,
two days ago, she was found wandering the
street and appears confused. The ambulance
crew who brought her to hospital has noticed
that she has been incontinent of urine.

On examination, she walks with a wide based
gait and has an MMSE score of 17 / 30. Her
temperature is 36.9°C and she has a CRP of 30
mg/l.

What is the most likely diagnosis?

1- Urinary tract infection

2- Subdural haematoma

3- Drug overdose

4- Normal pressure hydrocephalus

5- Alzheimer's disease

Answer & Comments

Answer: 4- Normal pressure hydrocephalus

Normal pressure hydrocephalus (NPH) is a
clinical symptom complex characterized by
abnormal gait, urinary incontinence, and
dementia. The CRP is not specific and there is
insufficient evidence for a UTI in this case.

[ Q: 678 ] MRCPass - Neurology

A 50 year old man presents with
weakness in his arms and legs which is worse
at the end of the day. On examination he has
bilateral ptosis and decreased reflexes.

What test will confirm that his muscle
weakness is due to Myasthenia Gravis rather
than Lambert Eaton myasthenic syndrome?

1- Tensilon test

This patient has parkinsonism, with
bradykinesia and rigidity. In view of the
deterioration in mental function and delusion,
Lew y body dementia is more likely than
Parkinson's disease.

2- Trial of pyridostigmine

3- Trial of prednisolone

4- EMG

5- Muscle biopsy

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Answer & Comments

Answer: 4- EMG

The main differential is myasthenia gravis and
LEMS. Myasthenia gravis can be differentiated
from Eaton Lambert myasthenic syndrome by
electromyography. Repetitive stimulation in
myasthenia gravis leads to a decrement of
evoked muscle action potentials, whilst in
myasthenic syndrome the condition improves
by repetitive stimulation.

[ Q: 679 ] MRCPass - Neurology

A 60 year old patient has been
confused for 1 week. His wife also mentions
he had two episodes of tonic clonic seizures.
He has a recent diagnosis of small-cell lung
cancer which is treated with radiotherapy.

What is the diagnosis?

1- Myasthenia gravis

2- Meningitis

3- Paraneoplastic syndrome

4- Cerebellar stroke

5- Wilson's disease

Answer & Comments

Answer: 3- Paraneoplastic syndrome

A wide variety of paraneoplastic neurological
manifestations have been described, but
parkinsonism is uncommon. Cerebellar
degeneration, tremor and movement
disorders, and Lambert Eaton Myasthenic
syndromes are the commonest.

^ [ Q: 680 ] MRCPass - Neurology

A -

# A patient has marked dizziness and
unsteadiness during walking. On examination,
he has a left sided Horner's syndrome and left
sided weakness. There is loss of sensation to
pinprick on the right side.

What is the likely diagnosis?

1- Left internal capsule infarct

2- Posterior inferior cerebellar artery
occlusion

3- Medullary infarct

4- Multiple sclerosis

5- Vertebral artery dissection

Answer & Comments

Answer: 2- Posterior inferior cerebellar artery
occlusion

Also known as Wallenberg's syndrome, the
signs are

vertigo, ipsilateral cerebellar signs and
weakness, and contralateral sensory loss.
There is also cranial nerve

involvement causing dysphagia and dysarthria.

[ Q: 681 ] MRCPass - Neurology

A 55 year old man has type 2
diabetes. He complains of difficulty walking.
On examination, he is unable to evert his right
foot. He has intact knee reflexes. There is also
sensory loss in the lateral aspect of the foot to
pin prick.

Which nerve root is involved?

1- L2

2- L3

3- L5

4- SI

5- S2

Answer & Comments

Answer: 3- L5

The common peroneal nerve is involved.
Nerve roots L5 and SI supply the nerve for
foot eversion.

The cutaenous sensory supply corresponds to
the lateral part of the foot.

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[ Q: 682 ] MRCPass - Infectious
disease

A 50 year old woman returned from Sri Lanka
several days ago. She presents to hospital with
headaches, myalgia and a fever of 38.5°C.

Examination reveals multiple petechiae.

Her bloods show Hb 13 g/dl, WCC 11 x 10 9 /L,
platelet count 70 x 10 9 /L

Thick and thin films for malaria are negative.

Which one of the following infections is most
likely?

1- Plasmodium malariae

2- Brucella

3- Rickettsia

4- Plasmodium ovale

5- Dengue fever

Answer & Comments

Answer: 5- Dengue fever

Dengue fever is a condition caused by an RNA
arbovirus which is common in tropical and
subtropical areas, particularly India, South
East Asia and the Pacific. Fevers, joint pains,
myalgia, rash and retro-orbital pain are
common. A petechial rash suggests the
possibility of impending serious sequelae
(dengue haemorrhagic fever/shock syndrome)
and indicates that she has been previously
infected with another serotype.

[ Q: 683 ] MRCPass - Infectious
disease

A 25 year old man presents with middle lobe
pneumonia. He is allergic to penicillin, so
cefuroxime is considered for treatment.

What is the risk of allergy to a cephalosporin
antibiotic in someone with a penicillin allergy?

1- 1 in 10000

2- 1 in 1000

3- 1 in 100

4- 1 in 10

5- All are allergic

Answer & Comments

Answer: 4-1 in 10

The risk of allergy is usually 5-10%.

A 25 year old man presented to an emergency
department with a 1-day history of fever,
headache and myalgia.

Two weeks before his presentation, he had
returned from a 10-day trip to Costa Rica,
where he had injured the sole of his foot on
coral. After injuring his foot, he had swum in
freshwater rivers. Thick and thin blood films
examined at the time for malaria parasites
were negative.

What is the likely diagnosis?

1- Amoebiasis

2- Leishmaniasis

3- Schistosomiasis

4- Leptospirosis

5- Brucella abortius

[ Q: 684 ] MRCPass - Infectious
disease

Answer & Comments

Answer: 4- Leptospirosis

Leptospira species are endemic in feral and
domestic mammals, reptiles and amphibians.
Rats and other rodents are the most
important sources for human infection. This
usually occurs through contact with urine-
contaminated soil or water, contact with
infected animal tissue, or through rat bites.

Pathogenic leptospiras rapidly invade the
bloodstream after penetrating skin or mucous
membranes, and multiply in small blood vessel
endothelium, resulting in damage and
vasculitis in major organs. The mortality rate
ranges from 4% to 10%, and adverse

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indicators are dyspnoea, oliguria, raised white
cell count, abnormalities on ECG, and alveolar
infiltrates on chest x-ray.

Oral doxycycline is highly efficacious.

A 2 year old, was brought to casualty with a
running nose, sneezing, and slight irritability.
Her mother said that child was healthy and
was running around until several days ago.

No specific treatment was initiated for this
"mild cold". Two weeks later, her mother
returns because the child had a cyanotic
(turned blue) episode during a coughing spell.
She indicates that the cough appears to be
worsening, particularly at night. It often
comes in spasms and she hears "gasping"
sound after a coughing spell, and he
frequently vomits after coughing.

On examination, he appears mildly
dehydrated but not distressed. His body
temperature is 37.2°C. His chest is clear and
his abdominal examination is normal. A full
blood count reveals leucocytosis and a marked
lymphocytosis.

What is the likely diagnosis?

1- Whooping cough

2- Tuberculosis

3- Epiglottitis

4- Pneumococcal pneumonia

5- Varicella pneumonia

[ Q: 685 ] MRCPass - Infectious
disease

Answer & Comments

Answer: 1- Whooping cough

Whooping cough (pertussis) is caused by the
gram negative bacterium Bordetella pertussis.
Infection is characterised by paroxysms of
coughing (with a 'w hoop'). Lymphocytosis is
commonly seen.

A 45 year old HIV positive man presents with
breathlessness. He has a temperature of 38°C.
The blood gases show a pH of 7.30, p0 2 of
8kPa and pC0 2 of 3 kPa. CXR shows bilateral
interstitial and alveolar consolidation.

Which of the following medications should be
used?

1- Quadruple anti TB therapy

2- Amphotericin

3- Co-trimoxazole

4- Gentamicin

5- Teicoplanin

[ Q: 686 ] MRCPass - Infectious
disease

Answer & Comments

Answer: 3- Co-trimoxazole

The patient has pneumocystis carinii
pneumonia and is hypoxic on the blood gases.
IV co-trimoxazole, clindamycin or pentamidine
can be used to treat this.

[ Q: 687 ] MRCPass - Infectious
disease

A 42 year old woman is referred to A&E with
bilateral leg weakness 6 weeks after returning
from a holiday in Eastern Europe. She also
complains of general malaise.

On examination she appeared unwell and was
had a temperature of 38.8°C. She has cervical
lymphadenopathy.

Her pharynx was inflamed with areas of
exudate on the pharyngeal wall.

What is the most likely diagnosis?

1- Campylobacter infection

2- Staphylococcal sore throat

3- Infectious mononucleosis

4- Hodgkin's disease

5- Diphtheria

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Answer & Comments

Answer: 5- Diphtheria

Diphtheria is an acute disease caused by
Corynebacterium diphtheriae, still more
common in Eastern Europe. The diagnosis is
clinical but can also be confirmed by culture of
the organism from a throat swab.

Diphtheria anti-toxin should be given
intramuscularly if there is any clinical
suspicion of diphtheria. Penicillin or
erythromycin should be given for a week.

3- Bartonella

4- Streptococcus viridans

5- Coxsackie virus

Answer & Comments

Answer: 5- Coxsackie virus

The clinical presentation is consistent with
myocarditis. Myocarditis can present with
pleuritic chest pains as well as troponin rise
and T wave inversion on the ECG. The
commonest organism is coxsackie virus
(serology can measure this). Other causes are
influenza, rubella, diphtheria, typhoid and
tuberculosis.

A 25 year old student returns from Ghana with
fevers and nocturnal sweats. She has a blood
film showing 5.5% of red blood cells infected
with plasmodium falciparum. She was
commenced on intravenous quinine due to
the high parasite count.

Which one of the following is a well known
side effect of quinine therapy?

[ Q: 689 ] MRCPass - Infectious
disease

Diphtheria

1- Diarrhoea

[ Q: 688 ] MRCPass - Infectious
disease

A 40 year old lady presents with fevers and
chest pains. The chest pains are worse when
she takes a deep breath. Her temperature is
38.9°C, BP 105/70 mmHg and pulse 110. An
ECG shows diffuse T wave inversion. An
echocardiogram shows mild tricuspid
regurgitation, no vegatations on any valves
and no pericardial effusion. Her troponin T is
0.3 ng/mL (normal <0.05).

Which of the following organisms is most
likely?

1- Respiratory syncytial virus

2- Legionella

2- Hypoglycaemia

3- Psychosis

4- Lipodystrophy

5- Deranged liver function

Answer & Comments

Answer: 2- Hypoglycaemia

Quinine can be given orally to treat falciparum
malaria. Intravenous infusion of quinine is
usually indicated only in severe cases (e.g.
cerebral malaria).

Hypoglycaemia is an important side effect of
quinine therapy. Glucose should be monitored
in those having intravenous quinine.

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[ Q: 690 ] MRCPass - Infectious
disease

A 25 year old man developed progressive
pneumonia which is responding poorly to
amoxycillin. Methenamine silver staining of
his sputum showed small circular cysts.
Giemsa staining demonstrated small, punctate
nuclei of trophozoites and intracystic
sporozoite.

Which is the likely organism?

1- Mycobacterium tuberculosis

2- Leishmania donovani

3- Pneumocystis carinii

4- Toxoplasma gondii

5- Trypanosoma cruzi

Answer & Comments

Answer: 3- Pneumocystis carinii

Pneumocystis carinii may be identified on
microscopy after

(a) methenamine silver staining which shows a
cystic phase of the organism

(b) Giemsa staining which demonstrates
sporozoites and trophozoites with small,
punctate nuclei.

[ Q: 691 ] MRCPass - Infectious
disease

A 75 year old woman presents with a Two day
history of confusion. She had complained to
her husband of a headache and neck stiffness.
A lumbar puncture was performed. CSF
microscopy revealed:

WBC 650 cells/mL (< 5)

90% neutrophils

A few Gram positive diplococci on staining
Whot is the likely cause of her meningitis?

1- Listeria monocytogenes

2- Streptococcus pneumoniae

3- Neisseria meningitidis

4- HIV

5- Herpes simplex

Answer & Comments

Answer: 2- Streptococcus pneumoniae

Streptococci are gram positive cocci.
Pneumococcal meningitis is commoner in
older patients. Neisseria meningitidis are gram
negative diplococci, whilst listeria
monocytogenes is a small gram positive
bacillus.

[ Q: 692 ] MRCPass - Infectious
disease

A 42 year old lady presented with cough,
shortness of breath and confusion. She was
admitted to hospital with a diagnosis of
pneumonia. Pulse oximetry showed an oxygen
saturation of 86 percent on air. Her chest x-
ray showed increased markings at the base of
the right lung.

A sputum culture grew normal flora, and Two
blood cultures showed no growth. Paired sera
taken on showed raised antibody titres to
Chlamydophila antigens (from <1:10 to 1:320).

What is the diagnosis?

1- Mycoplasma pneumoniae

2- Legionaire's disease

3- Byssinosis

4- Psittacosis

5- Pulmonary eosinophilia

Answer & Comments

Answer: 4- Psittacosis

Psittacosis is caused by chlamydia psittaci. It is
spread by all sorts of birds, not just pigeons or
parrots. Children are less predisposed than
adults to the disease. The disease does spread
from person to person. Treatment is with
tetracycline.

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^ Q: 693 ] MRCPass - Infectious
I disease

A 45 year old lady is being vaccinated
following a recent relative being diagnosed
with meningitis.

Vaccines exist in the UK for which major
groups of meningococcus?

1- B

2- A and C

3- B and C

4- A and B

5- A, B and C

Answer & Comments

Answer: 2- A and C

The vaccine for A has been used for travellers
for some years, and the vaccine for C has been
introduced more recently for high risk groups.

[ Q: 694 ] MRCPass - Infectious
disease

A 18 year old student is admitted with a
history of headaches, lethargy, anorexia and
vomiting of a few weeks duration. She had 2
witnessed seizures. Over the last few months
she has been treated for oral thrush.

On examination she is febrile, drowsy and she
has neck stiffness. CT scan of her head is
unremarkable.

CSF shows:

4- Herpes simplex virus

5- Mycobacterium tuberculosis

Answer & Comments

Answer: 3- Cryptococcus neoformans

The patient has chronic meningitis with raised
CSF lymphocytosis.

Immunosuppression is suggested by oral
candidiasis. The likely cause is cryptococcal
meningitis.

[ Q: 695 ] MRCPass - Infectious
disease

A 40 year old man has symptoms of diplopia,
dysphagia and dysarthria. After 12 hours he
develops weakness of his arms but remains
afebrile and is alert.

Following this, in the next 12 hours, he
deteriorates to the extent of requiring
artificial ventilation.

What is the likely diagnosis?

1- Diphtheria

2- Polio

3- Strychnine poisoning

4- Tetanus

5- Botulism

Answer & Comments

Answer: 5- Botulism

White cells 80 /ml (65% lymphocyte, 35 %
polymorphs)

Protein 1.2g/L

Glucose 2.5 mmol/L

Which organism is the likely cause of the
condition?

1- Meningococcus

2- Streptococcus

3- Cryptococcus neoformans

Botulism typically produces a descending
paralysis which starts with diplopia or blurred
vision due to difficulty with accommodation
and progresses to weakness of the neck, arms
and respiratory muscles. Botulism is caused by
the neurotoxins of Clostridium botulinum and
in rare cases, Clostridium butyricum and
Clostridium baratii. These gram-positive
spore-forming anaerobes can be found in soil
samples and marine sediments throughout
the world. Therapy consists of approximately
10,000 IU of antibodies against toxin types A,

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B, and E to neutralize serum toxin
concentrations, and also supportive care (e.g.
ventilation).

Tetanus and strychnine poisoning both
produce muscle spasm which may lead to
respiratory failure but not muscle weakness.

A 35 year old secretary returns from Mumbai
in India following a 2 week holiday. He had
headaches, arthralgia, myalgia,

diarrhoea/contipation and was mildly
confused. Malarial film was negative.

What is the likely diagnosis?

1- HIV

2- Syphilis

3- Schistosomiasis

4- Plasmodium ovale malaria

5- Typhoid fever

Answer & Comments

Answer: 5- Typhoid fever

Headaches, arthralgia, myalgia,

diarrhoea/contipation and confusion or
delirium can occur in typhoid fever (caused by
S typhi) which should be suspected in
travellers with pyrexia. Jaundice does not
occur.

[ Q: 696 ] MRCPass - Infectious
disease

Salmonella typhi

•i

i j

A 22 year old man who is asymptomatic has
been referred by the GP for investigation of
lymphadenopathy.

On examination, he has palpable cervical
lymph nodes. The Chest X ray is normal.

Which one of the following tests should be
done?

1- Fine needle aspiration and cytology

2- Excision biopsy

3- CT scan of the head and neck

4- Bone marrow biopsy

5- Genetic karyotyping

[ Q: 697 ] MRCPass - Infectious
disease

Answer & Comments

Answer: 1- Fine needle aspiration and cytology

As the patient is asymptomatic, there is little
clue towards a diagnosis. A needle aspiration
and cytology is essential to exclude lymphoma
/ carcinoma /TB. Other possible causes are
infection e.g. HIV or infectious mononucleosis.

[ Q: 698 ] MRCPass - Infectious
disease

A 40 year old man presented to hospital with
fever, intermittent rigors and lethargy. He had
returned from a holiday to West Africa six
months previously.

What is the likely diagnosis?

1- Plasmodium falciparum malaria

2- Plasmodium ovale malaria

3- Typhoid fever

4- Brucellosis

5- Leishmaniasis

Answer & Comments

Answer: 2- Plasmodium ovale malaria

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Plasmodium ovale malaria and its cyclic
paroxysms occur every 48 hours (tertian
fever). Plasmodium ovale is the rarest of the
four species and is apparently more restricted
in distribution.

However, it is common in the West African
countries of Ghana, Liberia, and Nigeria.

[ Q: 699 ] MRCPass - Infectious
disease

A 25 year old veterinarian presents with a 2
week history of high fevers, night sw eats, dry
cough, and myalgia.

He had no medical history and was taking no
regular drug treatment. A travel and
occupational history showed that he had lived
and worked as a vet in northern India until 6
months ago, when he moved to London.

On examination, the patient had a fever of
38.5°C, a solitary cervical lymph node
measuring 1 cm x 0.5 cm in size, and a
palpable splenic tip.

Initial investigations showed a CRP of 84 U/l
and white cell count of 4.8 x 10 9 /L. Three
blood films for malaria parasites were
negative. Standard liver function tests showed
a raised serum alkaline phosphatase
concentration of 520 U/l, a raised (gamma)-
glutamyltransferase concentration of 450 U/l,
and a raised serum aspartate
aminotransferase concentration of 248 U/l);
the serum bilirubin concentration was at the
upper end of the normal range, at 18 pmol/l.
The serum angiotensin converting enzyme
concentration was also raised, at 113 U/l.

Which one of the following tests is most likely
to yield the diagnosis?

1- Chlamydia serology

2- Mycoplasma serology

3- Brucella serology

4- Legionella serology

5- Paul bunnell test

Answer & Comments

Answer: 3- Brucella serology

The occupation suggests that the patient had
worked with animals e.g. cattle. Brucella is
transmitted through milk and meat, especially
in abbatoirs. The commonest cause is Brucella
melitensis. Detection of brucella may require
extended culture of 6 weeks and blood agar
plates. Detection of Brucella agglutinins (with
the Coomb's test) also helps confirm the
diagnosis.

Fever and rigors, followed by possible
osteomyelitis, polyarthritis, endocarditis,
pneumonia, hepatitis/jaundice, splenic
abscess, meningitis/encephalitis, skin changes,
orchitis/cervicitis and retinitis.

Past infection causes positive serology and
does not necessarily indicate active infection.
Tetracycline and gentamicin are treatments of
choice (better intracellular penetration).

Brucella melitensis - Gram-negative, aerobic,

coccobacillus

A 31-year-old white male presented to a
general practitioner with a tw o-day history of
fever, headaches, generalised aches and
pains, lethargy and loss of appetite. He had
travelled to Papua New Guinea 2 months ago.

A full blood count showed: lymphocytes, 0.71
x 10 9 /L; nneutrophils, 1.95 x 10 9 /L; and
platelets, 33 x 10 9 /L; normal, 150-450 x 10 9
/L). Haemoglobin concentration was in the
normal range. Blood film shows schizonts.

Which one of the following is the most likely
organism?

1- Schistosoma

[ Q: 700 ] MRCPass - Infectious
disease

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2- Mycobacterium tuberculosis

3- Pasteurella

Alkaline phosphatase: 120 U/l
HbsAg positive

4- Plasmodium vivax

IgG anti-HBc positive

5- Leptospira

Answer & Comments

Answer: 4- Plasmodium vivax

The history and FBC count is most consistent
with malaria. In this case, vivax malaria.

Plasmodium vivax trophozoites

[ Q: 701 ] MRCPass - Infectious
disease

During routine medical evaluation, a 30 year
old man was found to have abnormal liver
tests. A history failed to identify a clinically
recognized, past episode of acute hepatitis.
The patient had never received a blood
transfusion. He had not used injection drugs.
He had had unprotected sexual encounters
with multiple partners over several years.

On physical examination, he had no signs of
chronic liver disease. On receiving the
following results from the laboratory, the GP
referred him to a liver specialist.

Laboratory Results:

ALT: 180
AST: 140 IU

Bilirubin: 15 umol/l

HbeAg positive

HBV DNA 1.5 x 10 7 copies/ml

A liver biopsy showed moderately active
hepatitis with a necroinflammatory histologic
activity index score of 10/18 and a fibrosis
score of 3/6.

What should be done?

1- Commence inferferon alpha

2- Commence prednisolone

3- Commence ribavirin

4- Observation for several months

5- Refer for liver transplant

Answer & Comments

Answer: 4- Observation for several months

A case of hepatitis B with mildly deranged liver
function tests. There are signs of hepatitis
which are mild, and the liver function tests are
not significantly deranged, hence observation
of inflammatory activity is recommended.

A 35 year old man is very unw ell. He has had
a headache for 2 weeks and this is now
associated with neck stiffness and
photophobia. On examination, he has
temperature of 38.5°C, white lesions on the
tongue and axillary lymphadenopathy.
Fundoscopy is normal. CXR was normal. An
enhanced CT head scan is also normal.

Blood tests show lymphopenia.

What is the most likely diagnosis?

1- Secondary syphillis

2- Herpes simplex encephalitis

3- Cerebral toxoplasmosis

[ Q: 702 ] MRCPass - Infectious
disease

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4- Disseminated candidal infection

5- Cryptococcal meningitis

Answer & Comments

Answer: 5- Cryptococcal meningitis

The major clinical syndromes caused by the
genus Leishmania are cutaneous, mucosal and
visceral leishmaniasis. Leishmaniasis is
transmitted by Phlebotomus or Lutzomyia
sandflies and infects dogs and foxes as well as
humans.

Lymphopenia suggests HIV infection and this
patient also has candidal infection in the oral
cavity suggesting immunodeficiency. Hence
cryptococcal meningitis (which usually
presents in an indolent manner) is the most
appropriate answer.

[ Q: 703 ] MRCPass - Infectious
disease

A 22 year old man had been to a Greek island
on holiday 2 months ago. He presented with a

2-w eek history of dry cough, diarrhoea,
lethargy, anorexia and fever. He had a past
history of cutaneous vasculitis of uncertain
aetiology. He was not taking any regular
medication.

On examination, the patient's temperature
was 37.5°C, but no other abnormalities were
evident. Investigations showed that he had
pancytopenia, raised erythrocyte

sedimentation rate and

hypergammaglobulinaemia.

A second bone marrow biopsy at this time
revealed occasional macrophages containing
amastigotes. Further history revealed that he
had been bitten by sandflies.

Whot is the diagnosis?

1- Schistosomiasis

2- Cutaneous leishmaniasis

3- Visceral leishmaniasis

4- Malaria

5- Dengue fever

Answer & Comments

Answer: 3- Visceral leishmaniasis

Visceral leishmaniasis is caused by Leishmania
donovani, L. infantum or L. chagasi.

The incubation period of visceral leishmaniasis
is usually 2-8 months. Many infections are
subclinical, but the classic presentation is with
fever, weight loss, hepatosplenomegaly,
pancytopenia and hypergammaglobulinaemia.

The definitive diagnosis depends on
demonstrating either amastigotes in tissue or
promastigotes in culture. Splenic puncture is
the most sensitive means of obtaining a
diagnosis, but biopsy of the bone marrow and
liver is almost as good.

Pentavalent antimony compounds have been
used to treat leishmaniasis for decades, but
often have severe side effects, and resistance
is developing.Amphotericin can achieve 98%
long-term cure in both

antimonialunresponsive and previously
untreated patients.

A 33 year man chronic hepatitis C admitted
general deterioration. He missed many of his
previous outpatient appointments currently
receiving any treatment. On examination he
had a temperature of 38°C, and was
jaundiced.

His blood tests were:

Hb 12.0 g/dl
MCV 90 fl
WCC 9 x 10 9 /L
platelets 180 x 10 9 /L
urea 25 pmol/l
creatinine 340pmol/l

[ Q: 704 ] MRCPass - Infectious
disease

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sodium 138 mmol/l
potassium 3.5 mmol/l
bilirubin 60 pmol/l
AST 85 U/l
ALP 350 U/l
albumin 32 g/l
CRP 110 mg/I

Which of the following is likely?

1- Hepatocellular carcinoma

2- Acute liver decompensation

3- Hepatorenal syndrome

4- Superimposed HIV infection

5- Hepatitis delta infection

The diagnosis is non gonococcal urethritis.
This is commonly due to Chlamydia.
Treatment of choice is doxycycline.

A 30 year old man presents to your office after
passing something he thought was a
rubberband in his stool. He was worried when
he saw the object moving in the toilet. He is
otherw ise healthy and is taking no
medications. He has had no recent changes in
bowel habits or stool appearance. He denies
fever, abdominal pain, cough, or rash.

Whot is the likely diagnosis?

1- Hookworm

[ Q: 706 ] MRCPass - Infectious
disease

Answer & Comments

Answer: 3- Hepatorenal syndrome

The deranged LFTs and also impaired renal
function suggests hepatorenal syndrome.
Hepatitis delta (HepD) infection is
superimposed with Hepatitis B infection.

/*■'

[ Q: 705 ] MRCPass - Infectious
disease

A 19 year old female has a several day history
of urethral discharge. Mid stream urine is
negative. A swab was sent but no organisms
were grown.

Which one of the following should be
prescribed?

1- Penicillin V

2- Trimethoprim

3- Metronidazole

4- Doxycycline

5- Ciprofloxacin

2- Schistosomiasis

3- Ascariasis

4- Leishmaniasis

5- Echinococcus

Answer & Comments

Answer: 3- Ascariasis

Ascaria lumbricoides is roundw orm which
infects the ileum and may cause Gl symptoms.
It also causes pneumonitis and bronchospasm
when the larvae migrate via the bloodstream
to the alveoli. Once mature they crawl back up
the bronchi into the gut. Mebendazole, 100
mg orally tw ice daily for 3 days or 500 mg
orally once, is the treatment of choice.

Answer & Comments

Answer: 4- Doxycycline

Ascaris lumbricoides

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[ Q: 707 ] MRCPass - Infectious
disease

A 40 year old single man returned
from holiday in Europe with bloody diarrhoea
which had lasted for Two weeks.

He had lost 1 kg in weight, and has occasional
low er abdominal cramping discomfort. He
also has a painful sw elling in his right elbow.

Which is the likely couse?

1- Bacillus cereus

The patient follow ed Two but not three-step
commands.

A provisional diagnosis of an aphasic temporal
lobe lesion was made. A CT scan showed a low
attenuation lesion involving the medial and
posterior aspect of the left temporal lobe and
inferior basal ganglia.

Which of the following is likely?

1- Polymorpho leukoencephalopathy

2- Cerebral toxoplasmosis

2- E coli diarrhoea

3- Gonococcal septicaemia

4- Amoebiasis

3- Herpes simplex encephalitis

4- Multiple sclerosis

5- Meningococcal meningitis

5- Campylobacter infection

Answer & Comments

Answer: 5- Campylobacter infection

Reactive arthritis, which is the likely cause of
elbow sw elling in this case, can develop
following infection with Shigella, Salmonella,
Campylobacter and Yersinia. All these
organisms are common in travel to Europe or
North Africa

Campylobacter infection is one of the
commomest causes of inflammatory
diarrhoea. Abdominal pain is often a
prominent feature of the illness, frequently at
the right iliac fossa. The diarrhoea is often
bloody. Symptoms last for a w eek typically.

E coli diarrhoea is less likely to be associated
with a reactive arthritis.

[ Q: 708 ] MRCPass - Infectious
disease

A 62 year old lady presents with fever and
persistent difficulty in speaking. Her signs
show a termperature of 39°C. The patient was
alert and oriented with respect to time but
unable to name objects properly. Dysarthria
and occasional word substitution were noted.

Answer & Comments

Answer: 3- Herpes simplex encephalitis

Herpes simplex viruses (HSV-1 and HSV-2)
produce a variety of infections involving
mucocutaneous surfaces, the CNS, and
occasionally visceral organs. HSV encephalitis
is the most common identified cause of acute,
sporadic viral encephalitis. Clinically, HSV
encephalitis presents with acute onset of
fever and focal neurology, especially temporal
lobe signs.

A 18 year old man was admitted to the
emergency room due to fever, headache,
vomiting, irritability, and myalgia that had
begun 24 hours ago. There was no evidence of
previous infection in the upper airw ays. On
examination, the patient was lethargic,
disoriented and hypotensive, with petechiae
in the legs and upper limbs, and he had
conjunctival suffusion.

Cerebrospinal fluid (CSF) was turbid, with
5300 cells/ mm 3 (97% neutrophils and 3%
monocytes)and protein was 0.9 (<0.5).

Whot is the treatment of choice?

1- Erythromycin

[ Q: 709 ] MRCPass - Infectious
disease

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2- Gentamicin

3- Ceftriaxone

4- Metronidazole

5- Hydrocortisone

Answer & Comments

Answer: 3- Ceftriaxone

The patient has meningococcal meningitis
(suggested by the purpuric rash). Until the
organism (Neisseria meningitidis) is isolated
and sensitivities tested, the patient should be
on a cephalosporin or benzylpenicillin.

Meningococcal Rash

[ Q: 710 ] MRCPass - Infectious
disease

A 25 year old lady presents to A&E with a 3
day history of headache and fever. On
examination, she has neck stiffness and a
fever but no rash or focal neurology. She is
given IV ceftriaxone and a lumbar puncture is
performed.

CSF analysis shows:

Protein 0.35 g/L
Glucose 2/3 of plasma level

Microscopy shows 250 white cells,
predominantly lymphocytes

The most likely diagnosis is:

1- Listeria meningitis

2- Herpes simplex meningitis

3- Tuberculous meningitis

4- Meningococcal meningitis

5- Enteroviral meningitis

Answer & Comments

Answer: 5- Enteroviral meningitis

The CSF is suggestive of a viral as opposed to a
bacterial meningitis.

Enteroviruses are the commonest cause of
viral meningitis. The next best option would
be herpes simplex meningitis.

[ Q: 711 ] MRCPass - Infectious
disease

A 30 year old Turkish woman arrived in the UK
with a 6 month history of weight loss and
intermittent fevers. On examination, the
patient was febrile, an enlarged liver and
spleen were palpable.

Investigations revealed:
Haemoglobin 7.7 g/dL
White cell count 2.7 x 10 9 /L
Platelet count 95 x 10 9 /l_

Thick and thin films showed no malarial
parasites

Whot is the likely diagnosis?

1- Kawasaki's disease

2- Falciparum malaria

3- Visceral leishmaniasis

4- HIV infection

5- Tuberculosis

Answer & Comments

Answer: 3- Visceral leishmaniasis

The causative agent of visceral leishmaniasis is
Leishmania donovani.

Fever, malaise, anaemia, weakness and weight
loss are common presenting symptoms and
signs.

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Hepatosplenomegaly develops gradually and
also the skin develops a grey colour, giving rise
to the Indian name of the disease -'kala azar' -
meaning black fever.

[ Q: 712 ] MRCPass - Infectious
disease

A 35 year old man is admitted with a 5 day
history of fever, cough and lethargy.

On examination, he was pyrexial and had signs
consistent with a left low er lobe pneumonia.

In considering antibiotics for pneumonias ,
which one of the following microorganisms is
sensitive to Benzylpenicillin?

1- Klebsiella

2- Mycoplasma pneumoniae

3- Aspergillus fumigatus

4- Streptococcus Pneumoniae

5- Legionella pneumophila

increased protein of 1.2 mg/dL, cell count of 5
(all lymphocytes). She gradually recovers over
the next month.

Which of the following conditions is likely to
have preceded the onset of her illness?

1- Staphylococcus sepsis

2- CLL

3- Campylobacter infection

4- Folate deficiency

5- Behcet's syndrome

Answer & Comments

Answer: 3- Campylobacter infection

The overall diagnosis is Guillain Barre
syndrome, which causes peripheral sensori
motor neuropathy which is ascending. In
about half of all cases the onset of the
syndrome follows a viral or bacterial infection,
such as the following:

Answer & Comments

Answer: 4- Streptococcus Pneumoniae

Penicillin is mainly useful for Group A and
Group B Streptococci, meningococcal and
pneumococcal infections. Strep pneumonia is
one of the commonest organisms causing
community acquired bacterial pneunomia.

flu

gastrointestinal viral infection
infectious mononucleosis
viral hepatitis
Campylobacter
porphyria

[ Q: 713 ] MRCPass - Infectious
disease

A 45 year old woman develops a progressive,
ascending motor weakness over several days.
1 week ago she had been non specifically
unwell with fevers, diarrhoea and a dry cough.
Neurological examination revealed peripheral
low er motor neuron weakness and also
sensory loss to pain and touch.

She required intubation and ventilation
following rapid deterioration from admission.
A CT scan of her brain is normal. A lumbar
puncture is performed. The opening pressure
was normal. There was clear, colorless CSF,

An elevated level of protein in the CSF is
characteristic of GBS. Nerve conduction
studies may show changes consistent with
demyelination.

[ Q: 714 ] MRCPass - Infectious
disease

An 78 year old presents with confusion
associated with a chest infection. 4 days later
she developed green, then bloody diarrhoea.

Which of following organisms is likely to cause
the diarrhoea?

1- Methicillin resistant Staphylococcus aureus

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2- Salmonella

3- Clostridium difficile

4- Escherichia coli 0157

5- Campylobacter jejuni

Answer & Comments

Answer: 3- Clostridium difficile

This is a clinical scenario of Clostridium
infection causing pseudomembranous colitis
predisposed to by prior treatment broad
spectrum antibiotics such as cefuroxime or
augmentin.

[ Q: 715 ] MRCPass - Infectious
disease

A 25 year old man presented to the hospital
10 days after returning from a six month visit
to Pakistan. He had complained of fever,
rigors and headache. On examination he was
febrile (38°C) and his abdomen was tender in
the right upper quadrant.

Investigations showed:

Hb 10.0 g/dL

WBC 14.5 x 10 9 /L

Neutrophils 12.5 x 10 9 /l

Platelets 370 x 10 9 /L

Blood film - No malaria parasites seen

Aik Phos 480 iU/L

AST 60 iU/L

CRP 110 mg/L

Stool culture Negative

Chest xray: Small right pleural effusion

Which of the following investigations would be
of diagnostic value?

1- OGD

5- Stool for ova, cysts and parasites

Answer & Comments

Answer: 3- Ultrasound scan of the liver

The presenting features of RUQ pain and
pyrexia suggests a possible amoebic liver
abscess, hence an ultrasound of the liver to
look for it (this may be amenable to aspiration
and would confirm the diagnosis). Amoebic
cysts may also be found in the stool,
microscopy would be the next test to be done.

[ Q: 716 ] MRCPass - Infectious
disease

A 17 year old Sudanese boy was evaluated for
generalized pruritus and an eruption on his
legs. He complained of episodic decreased
visual acuity and eye pain every few months.
He denied fever, weight loss, or lethargy, and
his medical history was otherw ise
unremarkable.

A skin examination revealed diffuse xerosis
and lichenified, asteatotic patches distributed
over the knees and pretibia and on the dorsal
aspect of the feet. The affected skin was shiny
and atrophic in areas. There were also subtle
hypopigmented, xerotic patches over the
buttocks.

The peripheral blood cell count was normal
except for 30% eosinophilia (normal, <5.5%).
The eye examination (slitlamp and indirect
ophthalmoscopy) showed bilateral corneal
infiltrates.

What is the likely diagnosis?

1- Babesiosis

2- Trypanosomiasis

3- Onchocerciasis

4- Yellow fever

2- Typhoid serology

3- Ultrasound scan of the liver

4- Blood cultures

5- Herpes simplex infection

Answer & Comments

Answer: 3- Onchocerciasis

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Onchocerciasis (river blindness) is a common,
chronic, multisystemic disease caused by the
nematode Onchocerca volvulus. The disease
characteristically includes dermatologic,
lymphatic, ophthalmologic, and systemic
manifestations. Human transmission of the
disease is caused by a bite from the
intermediate host, the black fly (genus
Simulium). Treatment is with ivermectin.

Leopard-spot pattern of depigmentation on
the shins in onchocerciasis

[ Q: 717 ] MRCPass - Infectious
disease

A 38 year old woman has just returned from a
2 month holiday in East Africa. She mentions
that she had been swimming in fresh water.
She now has fevers, breathlessness and is
wheezy.

On examination, she has a generalized rash
and palpable hepatosplenomegaly.

Her investigations show : Hb 12.5 g/dl, WCC
14.5 x 10 9 /L, platelet count 190 x 10 9 /L. Thick
and thin malarial films are negative.

What is the likely diagnosis?

1- Schistosomiasis

2- Ankylostoma infection

3- Leishmaniasis

4- Amoebiasis

5- Infectious mononucleosis

Answer & Comments

Answer: 1- Schistosomiasis

Acute schistosomiasis can cause fevers, an
urticarial rash, diarrhoea,

hepatosplenomegaly (Katayama fever).

The clue here is sw imming. The larvae of
Schistosoma (known as cercariae) breed in
snails and are present in rivers and lakes. They
can penetrate human skin, and from there on
can migrate to organs such as lung or liver.

A rash known as 'swimmer's itch' or cercarial
dermatitis can occur. Pulmonary involvement
can lead to wheeze and breathlessness.

Leishmaniasis is spread by sandflies - there
may be hepatosplenomegaly, but there is
usually no pulmonary involvement.

Schistosomal egg from a tissue biopsy

[ Q: 718 ] MRCPass - Infectious
disease

A 22 year old man presents with pus
discharging from the urethra. Microscopy of a
sample of the pus showed neutrophils. There
were no organisms seen on gram stain.

Which of the following organisms is most
likely?

1- Ureaplasma urealyticum

2- Chlamydia trachomatis

3- Trichomonas vaginalis

4- Candidiasis

5- Neisseria gonorrhoeae

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Answer & Comments

Answer: 2- Chlamydia trachomatis

A patient who presents with urethral
discharge has either gonococcal or non¬
gonococcal urethritis (NGU). Since there were
no gram negative diplococci seen on
microscopy, it is NGU.

What is the most likely diagnosis?

1- Primary Syphilis

2- Infectious mononucleosis

3- Mycoplasma pneumonia

4- Wegener's granulomatosis

5- Parvovirus B19 infection

The organism are as follows:

■ Chlamydia trachomatis 40%
Ureaplasma urealyticum 20-40%
Trichomonas vaginalis (rare) < 2%
Candidasis (rare) < 2%

■ Herpes simplex (rare) < 2%

The most common organism is Chlamydia and
hence the best answer.

Chlamydia inclusions (intracellular parasites)

A 32 year old woman presents with a fever,
headache, cough, malaise and arthralgia. On
examination she has a w idespread maculo-
papular rash but no other findings. CXR is
normal.

Investigations show : Hb 13.6 g/dl, WCC 11 x
10 9 /L, platelets 220 x 10 9 /L, sodium 138
mmol/I, potassium 4.5 mmol/l, urea 5 pmol/l,
creatinine 110 pmol/l, CRP 115.

Cold agglutinin IgM antibody 1:64

FT-Antibodies negative

VDRL serology positive

[ Q: 719 ] MRCPass - Infectious
disease

Answer & Comments

Answer: 3- Mycoplasma pneumonia

Parvovirus B19 infection is unlikely with the
high CRP and syphilis is unlikely due to the
negative FTA-Antibodies. Mycoplasma
infection is a recognised cause of false positive
VDRL. Cold agglutinins also suggest M.
pneumonia IgM antibodies.

I J

A group of holiday makers have been to the
river Nile on a cruise holiday in Egypt. Many of
the tourists develop bloody diarrhoea a few
days later.

What is the likely organism?

1- Cryptosporidium

2- Entamoeba Histolytica

3- Shigella sonnei

4- Mycobacterium bovis

5- Giardia Lamblia

[ Q: 720 ] MRCPass - Infectious
disease

Answer & Comments

Answer: 3- Shigella sonnei

This is a smallprint fact but there is a past year
question based on travel to the Nile.

Salmonella, Campylobacter and shigella are
common causes of bloody diarrhoea among
people travelling in the region of Nile River
Delta of Egypt. E coli is also a cause of
diarrhoea, but not typically bloody.

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Shigella are non-motile gram-negative bacilli
that can cause diarrheal illness in humans.
Symptoms of a Shigella infection include
diarrhoea, fever, and abdominal cramps that
begin 24 to 48 hours after exposure. The
diarrhoea is often bloody.

[ Q: 721 ] MRCPass - Infectious
disease

A 65 year old man had been on holiday to
Arizona in the united states 6 weeks ago. He
was brought to hospital w ith high fever,
rigors, malaise, and mild confusion. He had a
generalised, non-pruritic maculopapular rash,
predominantly on the trunk but also on the
extremities, including the palms and soles.
There was no history of animal or arthropod
exposure, but his house was on the edge of
forest.

Whot is the most likely diagnosis?

1- Falciparum malaria

2- Rickettsial spotted fever

3- Tuberculosis

4- Allergic bronchopulmonary aspergillosis

5- Schistosomiasis

Answer & Comments

Answer: 2- Rickettsial spotted fever

Rocky Mountain or Rickettsial spotted fever
(RMSF), classically characterized by fever,
myalgias, headache, and a petechial rash, is
the most common tick-borne disease in the
United States. It is also found in Mexico and
South America, southern Africa, and Asia.

Recommended treatment is doxycycline.

Maculopapular rash due to Rickettsial disease

A 35 year old man presented to hospital with
a 7 day history of progressive severe thoracic
back pain and a 5 day history of left knee pain.
The back pain had occurred suddenly after
lifting weights, and radiated to the right chest
wall. His family history in relation to
rheumatological or inflammatory disorders
was unremarkable, and he had never used
intravenous drugs. He had no symptoms of
fever, conjunctivitis, urethritis, rash, early
morning joint stiffness or neurological
dysfunction.

On initial examination he looked well but had
a slightly raised temperature (37.8°C). There
was tenderness over the fifth to the seventh
thoracic vertebrae, and his left tibiofibular
joint was erythematous and warm.

Initial investigations revealed a neutrophil
leukocytosis of 9.5 x 10 9 /L (1.7-7.0 x 10 9 /L)
and raised C-reactive protein, 73 mg/L (< 3
mg/L) and erythrocyte sedimentation rate, 47
mm/h (0-10 mm/h). An MRI scan showed
epidural abscess.

What is the most likely organism?

1- Streptococcus pyogenes

2- Staphylococcus aureus

3- Pasteurella multicoda

4- Enterococcus faecalis

5- E coli

[ Q: 722 ] MRCPass - Infectious
disease

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Answer & Comments

Answer: 2- Staphylococcus aureus

Epidural abscesses are most commonly caused
by staph aureus. Patients typically present
with either a triad of tenosynovitis, dermatitis
and polyarthralgia without purulent arthritis,
or purulent arthritis without skin lesions. For
the Investigation of symptoms of localised
back pain and fever, magnetic resonance
imaging is the investigation of choice.

A 30 year old woman presents with a Two
week history of severe headache, myalgia and
a red maculopapular rash. She had returned
from Malaysia a week ago, where she
mentions she had been bitten by mosquitoes.

On examination his blood pressure was 80/45
mmHg. A diagnosis of dengue fever was likely.

Which of following is the best treatment
option?

1- Intravenous hydrocortisone

2- Intravenous fluids

3- Intravenous artemesinin

4- Ribavirin

5- Intravenous aciclovir

[ Q: 723 ] MRCPass - Infectious
disease

Answer & Comments

Answer: 2- Intravenous fluids

The treatment for Dengue fever is supportive
treatment with intravenous fluids (either
crystalloids or colloids). Steroids and antiviral
drugs have not been proven effective.
Artemisinin (Chinese wormwood) is used to
treat malaria.

[ Q: 724 ] MRCPass - Infectious
disease

An 18 year old boy has recently been to
Pakistan. He now presents to hospital with a

7-day history of a high fever and vomiting. He
had a soft palpable spleen. His total leukocyte
count was 3 x 10 9 /L Malarial parasites were
not seen on examination of thin and thick
smears of peripheral blood.

The results of a routine urinalysis and chest x
rays were normal. A blood Widal test showed
a titer of 320 against "O" (somatic) antigen of
Salmonella enterica serovar Typhi. Blood
culture yielded the growth of Salmonella
Typhi.

What should he be treated with?

1- Amoxycillin

2- Metronidazole

3- Ciprofloxacin

4- Tetracycline

5- Gentamicin

Answer & Comments

Answer: 3- Ciprofloxacin

This a case of typhoid fever. The non
blanching macular rash is known as 'Rose
Spots'.

Fluoroquinolones such as ciprofloxacin are the
most effective antimicrobial agents for
treating enteric fevers.

Rose Spots

^ [ Q: 725 ] MRCPass - Infectious

jJ[ | disease

A previously healthy 50 year old man has
recently been to the Amazon on a jungle
trekking trip. He returns with a 4-day history
of crampy abdominal pain and a 1-day history

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of fever of 39.3°C and severe headache. He
mentions he was bitten by mosquitoes
frequently during the trip.

On admission, physical examination revealed
an ill-appearing man. Laboratory tests
documented leukopenia, anemia (hemoglobin
10.5 g/dL), thrombocytopenia, abnormal
coagulation (INR 6.5), renal failure and
deranged liver function (AST: 13,700 U/L
[normal: 15-37 U/L].

Malarial film and rickettsial serology were
negative.

What diagnosis should be considered?

1- Chagas disease

2- Malaria

3- Yellow fever

4- Visceral leishmaniasis

5- Schistosomiasis

Answer & Comments

Answer: 3- Yellow fever

Yellow fever (YF) is a mosquitoborne viral
disease. Although no specific treatment exists
for YF and the case-fatality rate for severe YF
is approximately 20%, an effective vaccine is
available. Symptoms are of sudden onset of
fever, bradycardia and headache. Severe cases
progress to intense albuminuria , jaundice,
and hemorrhage.

A 65 year old woman has leg cellulits which is
not responding to antibiotics. Would swab
now grows MRSA.

Which would be the best antibiotic regime to
use in a patient who has spreading methicillin-
resistant Staphylococcus aureus infection of a
skin wound?

1- Gentamicin

2- Doxycycline

[ Q: 726 ] MRCPass - Infectious
disease

3- Flucloxacillin

4- Rifampicin

5- Vancomycin

Answer & Comments

Answer: 5- Vancomycin

Vancomycin should be used first line for MRSA
with rifampicin added for synergistic action.
More recently, oral linezolid has also been
show n to be effective.

A 30 year old Mexican male presented with 3
weeks history of fever, malaise, nausea,
vomiting and right upper quadrant pain. Bow
els were regular with normal stools.

On abdominal examination, there was right
upper quadrant tenderness without rigidity or
guarding. There was no organomegaly,
masses, or ascites and bow el sounds were
normal.

Liver functions showed elevated alkaline
phosphatase (152 IU/L) and a low albumin.

Abdominal CT scan showed a well-
demarcated abscess in the right lobe of liver.
Aspirate from the abscess is reddish brow n in
colour.

What is the likely diagnosis?

1- Tuberculous abscess

2- Malaria

3- Sarcoidosis

4- Schistosomiasis

5- Amoebic abscess

[ Q: 727 ] MRCPass - Infectious
disease

Answer & Comments

Answer: 5- Amoebic abscess

Amoebic liver abscess is caused by Entameba
histolytica.The trophozoites reach the liver via
portal circulation and block the small portal

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radicles leading to inflammation and
subsequent necrosis.

The abscess is commonly found in right lobe
of liver. Aspirate from the abscess is reddish
brow n "anchovy sauce" and mainly consists
of degenerate liver cells and blood.

The most common treatment of amebic liver
abscess is - Metronidazole 750 mg t.i.d. for 5-
10 days.

Amoebic liver abscess in the right lobe of the
liver

[ Q: 728 ] MRCPass - Infectious
disease

A 70 year old man with chronic renal failure
for which he receives regular haemodialysis
treatment, is admitted with fever and
lethargy. Blood cultures grow a vancomycin-
resistant enterococcus (VRE).

Which of the following drugs would be most
suitable?

1- Septrin

2- Meropenem

3- Enterocid

4- Linezolid

5- Vancomycin

Answer & Comments

Answer: 4- Linezolid

Vancomycin-resistant enterococci are an
emerging problem in hospitals, where

extensive glycopeptide use may select for
resistant strains. In noncomparative trials of
treatment of VRE infections,
quinupristin/dalfopristin and linezolid are
effective. Some are teicoplanin sensitive.

[ Q: 729 ] MRCPass - Infectious
disease

A 33 year old male presents with a history of
dysuria, and penile discharge. He had
unprotected sexual intercourse with a casual
partner 3 days prior to the development of
symptoms. An urethral swab is taken and on
gram stain this shows numerous polymorphs
with many intracellular gram-negative
diplococci.

The causative organism is:

1- Treponema pallidum

2- Ureaplasma urealyticum

3- Neisseria gonorrhoeae

4- Chlamydia trachomatis

5- Trichomonas vaginalis

Answer & Comments

Answer: 3- Neisseria gonorrhoeae

The presence of gram-negative intracellular
diplococci suggests the diagnosis is gonococcal
urethritis. Non-gonococcal urethritis (NGU)
may be due to Chlamydia trachomatis,
Trichomonas vaginalis, Ureoplasma
urealyticum, Mycoplasma genitilium and
Bactroides spp.

[ Q: 730 ] MRCPass - Infectious
disease

A 35 year old man has lymphopenia on his
white cell differential count. He has been
complaining of headaches over the last 6
weeks.

On examination, he has a temperature of 38.5
C and no focal neurological signs. A CT scan of

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his brain showed a 5 cm ring enhancing lesion
in the frontal lobe.

Which of the following organisms is likely?

1- Cryptosporidia

2- Toxoplasma gondii

3- Aspergillus

4- Cryptococcus neoformans

5- Mycobacterium avium intracellulare

Answer & Comments

Answer: 2- Toxoplasma gondii

The lymphopenia suggests HIV infection. Ring
enhancing lesions in the brain suggest either
cerebral toxoplasmosis or lymphoma.

Ring enhancing lesion in the Basal ganglia

[ Q: 731 ] MRCPass - Infectious
disease

A 28 year old lady present with a solitary,
crusted, thickened lesion on her leg 6 weeks
after returning from a holiday in a suburban
area in Sao Paulo, Brazil. She had no new
sexual contact whilst there. She thinks she
might have been bitten by some flies.

Whot is the likely diagnosis?

1- Cutaneous anthrax

2- Syphillis

3- Erysipelas

4- Onchocerciasis

5- Cutaneous leishmaniasis

Answer & Comments

Answer: 5- Cutaneous leishmaniasis

Cutaneous leishmaniasis can be caused by
several Leishmania species, including L.
braziliensis, L. mexicana and L. panamensis. It
is spread by sandflies. The incubation period is
variable, ranging from 2 weeks to several
months.

Lesions usually occur on sunexposed areas.
Diagnosis can be confirmed with biopsy
demonstrating amastigotes.

Treatment is usually with pentavalent
antimonial drugs (sodium stibogluconate).

Cutaneous anthrax is unlikely because it
usually occurs in patients who have contact
with meat, wool or hides e.g. veterinarians or
farm workers. Cutaneous onchocerciasis is
rare.

Cutaneous leishmaniasis: indolent, slow ly
healing lesion

Sandfly

A 38 year old woman has had multiple
resections of the bow el on account of

[ Q: 732 ] MRCPass - Infectious
disease

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recurrent Crohn's disease. This has resulted in
intestinal failure and she is dependent on
home parenteral nutrition. She has a central
line inserted.

She presents with fever accompanied by chills
and rigors. No physical signs are
demonstrable. Cultures taken both centrally
and peripherally demonstrate the presence of
methicillin-sensitive Staphylococcus aureus.

Whot should be done next?

1- Treatment with intravenous vancomycin for
14 days

2- Treatment with intravenous gentamicin for
14 days

3- Treatment with intravenous teicoplanin for
14 days

4- Remove the intravenous line

3- Pasteurella multicoda

4- E coli

5- Pseudomonas aeruginosa

Answer & Comments

Answer: 3- Pasteurella multicoda

Pasteurella multicoda is an oral commensal of
domestic pets known to be an opportunistic
human pathogen after traumatic animal
contact. The most common infections in
humans are skin and pulmonary infections.

Pasteurella meningitis occurs at extremes of
age (infants), in the immunocompromised
(associated with liver cirrhosis, renal disease
and haematological malignancies) and after
traumatic head injury.

5- 6 weeks of intravenous flucloxacillin and
gentamicin

Answer & Comments

Answer: 4- Remove the intravenous line

Line infection with Staphylococcus aureus and
Candida are absolute indications for line
removal.

[ Q: 733 ] MRCPass - Infectious
disease

A 2 year old girl presented with a 12-hour
history of fever and poor feeding. The family
ow ned Two cats. Her temperature was
39.5°C, and she was irritable, with no
localising signs or skin lesions. A full septic
screen was performed. Cerebrospinal fluid
(CSF) showed a neutrophilic pleocytosis and
gram-negative coccobacilli. She was treated
with intravenous cefotaxime and gentamicin.
Within 24 hours both CSF and blood cultures
showed growth of gram-negative bacilli.

What is the likely infective organism?

1- Legionella pneumophilia

2- Haemophilus influenzae

[ Q: 734 ] MRCPass - Infectious
disease

A 34 year old Turkish lady was admitted with
fever for the past few weeks. On examination
she was emaciated, with massive
splenomegaly and hepatomegaly.

What is the treatment of choice?

1- Ciprofloxacin

2- Symptomatic treatment

3- Pentavalent antimonial

4- Quinine

5- Praziquantel

Answer & Comments

Answer: 3- Pentavalent antimonial
The features of leishmaniasis are:
fever

hepatosplenomegaly

pancytopenia

Leishmaniases are widespread in most
countries in the Mediterranean basin,

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including Turkey. Treatment is with the
pentavalent antimonial - Sodium
stibogluconate.

[ Q: 735 ] MRCPass - Infectious
disease

A 40 year old man who is HIV positive has
been non compliant with antiretroviral
medication. He presents with progressive
(over 3 weeks) right sided upper and lower
limb weakness. MRI scan of the brain shows
multiple white matter lesions. CSF
examination showed normal cell count and no
organisms were seen. These lesions are non¬
enhancing.

Which one of the following is most likely?

1- Tuberculous infection

2- Progressive multifocal

leukoencephalopathy

3- Cerebral toxoplasmosis

4- Haemorrhagic stroke

5- Cryptococcal infection

Answer & Comments

Answer: 2- Progressive multifocal

leukoencephalopathy

Although all the diagnoses are possible the
presence of non-enhancing white matter
lesions suggest JC virus infection (PML). CSF
PCR reveals JC virus in >90% of cases. If the
lesions had been enhancing, toxoplasmosis
would have been the most likely answer and a
trial of sulphadiazine/pyrimethamine would
have been indicated.

[ Q: 736 ] MRCPass - Infectious
disease

A 55 year old man presents with confusion.
Along the way to the hospital, he had a
witnessed generalised tonic clonic seizure.

On examination, he had a temperature of 38 C
and MMSE score of 17/30. There was no focal
neurolgical signs and he did not have a cardiac
murmur. The admitting doctor organises a
lumbar puncture and MRI scan of the brain to
investigate the cause.

Which one of the following features would be
most suggestive of Herpes simplex
encephalitis?

1- Occipital change on MRI

2- Temporal lobe change on MRI

3- Negative CSF for bacteria and enteroviruses

4- Normal temperature

5- Lymphocytosis in CSF

Answer & Comments

Answer: 2- Temporal lobe change on MRI

HSV encephalitis is a rare disease but can
affect patients who are otherw ise fit and well.
Neurological signs occur in around a third of
cases. Fever is alw ays present. Typically the
temporal lobes are involved on MRI.

Subtype 1 virus accounts for 95% of cases.
Brain biopsy is the "gold standard" for
diagnosis but in practice a +ve PCR for HSV in
CSF confirms the diagnosis. Treatment is with
high-dose intravenous acyclovir.

Large PML lesion in the left frontal lobe

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Medial Temporal Lobe changes on MRI in HSV

encephalitis

A 40 year old African man, has been back to
Africa for a holiday for several weeks. 6
months after coming back to the UK, he
presented with fever and intermittent rigors.

What is the likely diagnosis?

1- Plasmodium malaria

2- Plasmodium falciparum

3- Plasmodium ovale

4- Dengue

5- Trypanosomiasis

[ Q: 737 ] MRCPass - Infectious
disease

Answer & Comments

Answer: 3- Plasmodium ovale

Plasmodium ovale produces hypnozoites
which are latent in the liver. Relapses can
occur up to 5 years after infection.
Plasmodium vivax infection may present
similarly.

Plasmodium ovale parasite

[ Q: 738 ] MRCPass - Infectious
disease

A 35 year old man with known HIV infection
presents with a headache and neck stiffness. A
lumbar puncture w as performed.

CSF analysis showed:

Protein 0.55 g

Glucose 3.3 (serum glucose 6.6)

White cells : 30 with lymphocytosis
What is the likely diagnosis?

1- Listeria meningitis

2- Tuberculous meningitis

3- HSV meningitis

4- Cryptococcal meningitis

5- Subarachnoid haemorrhage

Answer & Comments

Answer: 2- Tuberculous meningitis

The history of immunosuppression, low
glucose and lymphocytosis suggests
tuberculous meningitis.

[ Q: 739 ] MRCPass - Infectious
disease

A 45 year old man complains of general
malaise. He has just returned from a 2 week
holiday in Slovakia. On examination he
appeared was pyrexial and had large palpable
cervical lymph nodes bilaterally. His pharynx

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had areas of exudate with a pale grey
membrane.

What is the best treatment option?

1- Penicillin

2- Tetanus injection

3- Anti TB therapy

4- Amphotericin

5- Teicoplanin

Answer & Comments

Answer: 1- Penicillin

The diagnosis is diphtheria. Diphtheria can
cause sorethroat with exudate, fever, cervical
lymphadenopathy and occasionally
neurological signs of flaccid paralysis. The
illness is still present in Eastern Europe and
Russia. Treatment is with diphtheria antitoxin,
penicillin or erythromycin.

Southeast Asia, eastern Europe, and South
America. Cerebral cysticercosis may present as
epilepsy, meningoencephalitis or focal
neurological deficit. Subcutaneous
cysticercosis presents as hard, small, pea-sized
nodules in the subcutaneous tissues.
Praziquantel or albendazole with steroid cover
is the treatment of choice.

(

A 40 year old man is admitted for
investigation of fevers having recently come
back from Peru. The fever is intermittent and
comes on every 72 hours. He has
splenomegaly. A Giemsa stained thin blood
film shows malarial parasites.

Which species is it likely to be?

1- Plasmodium vivax

2- Plasmodium ovale

[ Q: 741 ] MRCPass - Infectious
disease

[ Q: 740 ] MRCPass - Infectious
disease

A 42 year old man emigrated to the UK from
South America 3 years ago. He has long
standing left hemiparesis and also visual loss
in the right eye. Several hard subcutaneous
nodules are noted on several areas on the
body.

Which one of the following is the likely
infection ?

1- Filariasis

2- Cysticercosis

3- Schistosomiasis

4- Syphilis

5- Cutaneous tuberculosis

Answer & Comments

Answer: 2- Cysticercosis

Cysticercosis is due to infection with Taenia
solium and human tissue is invaded by the
larval form. It commonly is found in Africa,

3- Plasmodium falciparum

4- Plasmodium malariae

5- Plasmodium knowlesi

Answer & Comments

Answer: 4- Plasmodium malariae

Plasmodium malariae causes quartan fever
(every 72 hours or fourth day) whereas the
other species cause tertian fever (every 48
hours or third day). It is found particulary in
temperate climates.

A 22 year old woman presented with a 1-day
history of fever, chills and severe back pain,
with no other focal symptoms. On
examination, she was febrile with a blood
pressure of 75/40 mmHg, and had begun
vomiting.

She was treated empirically with intravenous
ceftriaxone and flucloxacillin and resuscitated

[ Q: 742 ] MRCPass - Infectious
disease

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with intravenous fluids. Over several hours,
the back pain resolved, and a widespread
erythrodermic rash developed, centred mainly
on the trunk. Further questioning revealed
that the patient had removed a tampon
shortly before presentation, as she had just
ceased menstruating.

What is the diagnosis?

1- Haemolytic uraemic syndrome

2- E coli sepsis

3- Fungal infection

4- Toxic shock syndrome

5- Meningococcal septicaemia

Answer & Comments

Answer: 4- Toxic shock syndrome

Toxic shock syndrome is due to toxin-1 (TSST-
1), a protein secreted by S.

aureus or streptococci, was the first of many
toxins associated with the syndrome to be
identified. Treatment is with penicillin and
ceftriaxone.

A 55 year old man who has a known history of
chronic alcohol abuse presents with a week's
history of fevers, night sweats and a cough
productive of purulent sputum.

On examination he was pyrexial with a temp
of 39.1°C. Percussion note was dull over the
left apex and there was bronchial breathing
over this area on auscultation. The chest xray
showed left upper lobar consolidation.

Other investigations revealed:

WBC 19 x 10 9 /l_

Neutrophils 18.3 x 10 9 /L

What is the most likely diagnosis?

1- PCP

2- Tuberculosis

[ Q: 743 ] MRCPass - Infectious
disease

3- Mycoplasma pneumonia

4- Klebsiella pneumonia

5- Legionnella pneumonia

Answer & Comments

Answer: 4- Klebsiella pneumonia

Community acquired Klebsiella pneumonia is a
disease of commonly affecting middle aged to
older men with alcoholism. Klebsiella
pneumonia characteristically affects one of
upper lobes of the lung. There is an increased
tendency toward abscess formation.
Mycoplasma pneumoniae infections have a
more insidious onset.

[ Q: 744 ] MRCPass - Infectious
disease

A 23-year-old man presented to a hospital
with a 3 day history of fever, rigors, confusion
and malaise. A chest x-ray showed left low er-
lobe pneumonia. He works in a factory close
to a water tank which acts as a heat exchange
for the welding cooling system.

What is the most likely infective organism?

1- Pneumococcus

2- Legionella

3- Mycoplasma

4- Tuberculosis

5- Klebsiella

Answer & Comments

Answer: 2- Legionella

Legionnaire's disease is a severe form of
pneumonia caused by the gram negative
bacterium Legionella pneumophila. It is an
airborne infection with the bacterium
sometimes living in air-conditioning systems,
whirlpool spas and domestic hot water
systems in large buildings.

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[ Q: 745 ] MRCPass - Infectious
disease

A 34 year old man with HIV infection presents
with several episodes of seizures. His CD4
count is 150 cells/mm 3 . He had an MRI scan
which shows multiple ring enhancing lesions.

Whot should be given for treatment?

1- Prednisolone

2- Co-trimoxazole

3- Pyrimethamine

4- Foscarnet

5- Rifampicin

Answer & Comments

Answer: 3- Pyrimethamine

The likely diagnosis is cerebral toxoplasmosis.
Tuberculosis usually causes single enhancing
lesions and PML is less frequently ring
enhancing. Lymphoma is also possible but not
applicable in this scenario. Treatment for
cerebral toxoplasmosis is pyrimethamine and
sulphadiazine.

Ring enhancing lesion Overall, this question

has been

[ Q: 746 ] MRCPass - Infectious
disease

A 38 year old man who is an intravenous drug
abuser complains of chest pain and dyspnoea.

Chest X ray shows bilateral cavities at apex.

Whot is the most likely diagnosis?

1- Tuberculosis

2- Tricuspid endocarditis

3- Pulmonary embolism

4- Sarcoidosis

5- Extrinsic allergic alveolitis

Answer & Comments

Answer: 2- Tricuspid endocarditis

Right-sided endocarditis accounts for 5% of all
cases of infective endocarditis and it is most
often seen in intravenous drug abusers, the
immunosuppressed and patients with central
lines. The cavities on the chest x ray may
represent abscesses due to embolic
vegetations from endocarditis.

A 28 year old banker goes on holiday to Brazil.
He visits various holiday spots including a
cattle ranch. He has headaches and a
temperature of 38 °C. Examination reveals
hepatosplenomegaly and spinal tenderness.
His blood cultures do not grow any organisms.

Which is the likely infective organism?

1- Brucella melitensis

2- Listeria

3- Cryptosporidium

4- Shigella

5- Schistosomiasis

[ Q: 747 ] MRCPass - Infectious
disease

Answer & Comments

Answer: 1- Brucella melitensis

Brucella is spread by contact with cattle,
drinking unpasteurized/raw milk. It causes
sacroilitis and discitis, and hepatomegaly.
Should be treated by doxycycline or rifampicin

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^ [ Q: 748 ] MRCPass - Infectious

0 disease

A pregnant 18 year old woman came to the
clinic with a low -grade fever,malaise, and
headache. She was sent home with a
diagnosis of influenza. She again sought
treatment 7 days later with a macular rash on
her trunk, arms, hands, and feet. Further
questioning of the patient when serology
results were known revealed that I month
previously, she had a painless ulcer on her
vagina that healed spontaneously.

Which of the following is the most likely
diagnosis?

1- Lyme disease

2- Lymphogranumoma venereum

3- Behcet's disease

4- Endocarditis

5- Syphilis

Answer & Comments

Answer: 5- Syphilis

The initial lesion of primary syphilis develops
at the site of transmission after an incubation
period of 10-90 days, with a mean of about
21-28 days, and then heals spontaneously in

3-7 weeks.

T pallidum is sensitive to the penicillins and is
easily treatable in the early stages

Maculopapular rash in secondary syphilis

[ Q: 749 ] MRCPass - Infectious
disease

A 40 year old man has HIV infection. He is
admitted with a 4 month history of weight
loss, lethargy and diarrhoea.

He presented 6 months previously with PCP
pneumonia. He is on AZT, lamivudine and
efavirenz therapy.

Investigations reveal:

Hb 9.8 g/dl, WCC 6.5 x 10 9 /L, platelets 75 x
10 9 /L, MCV 95 fl, CD4 count 280 X 10 6 /ml, Aik
Phos 270 U/l, Bilirubin

8 U/l, ALT 20 U/l, GGT 30U/I.

CXR: normal.

What is the cause of the anaemia?

1- Upper Gl bleed

2- Haemolytic anaemia

3- Vitamin B i2 deficiency

4- Folate deficicency

5- Zidovudine therapy

Answer & Comments

Answer: 5- Zidovudine therapy

AZT has common side effects such as nausea
and headaches, anaemia, bone marrow
suppression and proximal myopathy. Some of
these side effects may be caused by the
sensitivity of ?-DNA polymerase in cell
mitochondria to AZT.

On the medical wards, there has been several
new cases of Clostridium difficile diarrhoea.

What is the best way to prevent spread of
Clostridium difficile?

1- Hand washing by staff and patients

2- Isolation of patients affected

3- Isolation of any staff affected

[ Q: 750 ] MRCPass - Infectious
disease

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4- Treatment of asymptomatic carriers with
oral vancomycin

5- Ward closure and sterilisation

Answer & Comments

Answer: 1- Hand washing by staff and patients

Infection control with hand washing has been
a topical issue and there is great emphasis on
the effectiveness of handw ashing to prevent
spread of many infections.

A 20 year old woman has fevers and central
chest pains which are pleuritic in nature. She
also gives a history of arthralgia. On
examination, she has a systolic murmur
loudest in the mitral region. She also has
serpigionous erythematous rash on the
abdomen and has subcutaneous nodules in
the right elbow.

Blood tests show Hb 9.8 g/dl, WCC 14 x 10 9 /L,
platelets 280 x 10 9 /L, CRP 120 mg/I.
Echocardiogram shows moderate mitral
regurgitation.

What is the likely diagnosis?

1- Coxsackie virus infection

2- Libman sacks endocarditis

3- Rheumatoid arthritis

4- Rheumatic fever

5- Lyme disease

[ Q: 751 ] MRCPass - Infectious
disease

Answer & Comments

Answer: 4- Rheumatic fever

The patient has symptoms which would satisfy
the Duckett Jones criteria for rheumatic fever.
Either 2 major, or 1 major/ 2 minor criteria
would be required with evidence of
Streptocoocal infection e.g. ASOT.

46 year old man has had a history of HIV
infection known for 6 years. He presented
with confusion and has had a lumbar
puncture.

Results of the CSF showed:

White cells 150 /mm 3
Glucose 4 mmol/I
Protein 0.55 g/l
What is the likely diagnosis?

1- AIDS dementia complex

2- CNS lymphoma

3- HSV encephalitis

4- Disseminated tuberculosis

5- Cerebral toxoplasmosis

[ Q: 752 ] MRCPass - Infectious
disease

Answer & Comments

Answer: 3- HSV encephalitis

The glucose is not sufficiently low to suggest
tuberculosis, and the scenario fits with HSV
encephalitis. This is not an AIDS defining
illness but does occur in patients who are
immunosuppressed.

A 25 year old lady has recently returned from
Namibia in Africa. On examination his
temperature was 38°C, and inspiratory
respiratory crackles were present. He had a
maculopapular rash and a few some blue-grey
spots in the buccal area.

Which of these diagnoses is likely?

1- Subacute sclerosing panencephalitis

2- Dengue fever

3- Measles

4- Behcet's disease

5- Rubella

[ Q: 753 ] MRCPass - Infectious
disease

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Answer & Comments

Answer: 3- Measles

Measles is still common in Africa, atlhough
immunisation has greatly reduced incidences
in many areas. The presentation is usually
with fever, dry cough, conjunctivitis, a rash,
lymphadenopathy or hepatosplenomegaly.
The blue-grey spots on the buccal mucosa are
known as Koplik spots. In young children,
latent infection can involve the central
nervous system - known as subacute
sclerosing panencephalitis. Treatment is with
supportive care.

Koplik's spots

[ Q: 754 ] MRCPass - Infectious
disease

A 25 year old male man has urethral
discharge. Gram stain of the discharge sample
shows gram negative intracellular diplococci.
The patient is treated with cefotaxime as a
500mg single intramuscular dose. A week
later, the patient still has urethral discharge.

Which of the following organisms is likely to be
responsible?

1- Neisseria gonorrhoeae

2- Ureaplasma

3- Chlamydia trachomatis

4- Staphyloccocus aureus

5- Escherichia coli

Answer & Comments

Answer: 3- Chlamydia trachomatis

Although the diplococci are likely to be
gonorrhoea, this patient has been treated and
it makes this less likely. Recommended
treatment options for gonococcal infection are
ceftriaxone 250mg single im dose OR
cefotaxime (Claforan) 500mg single im dose
for gonorrhoea. Persistent discharge suggests
another organism, in this case likely
Chlamydia. Doxycycline would is therefore
recommended.

A 22 year old girl presents with headache and
neck stiffness. She was pyrexial but had no
signs of raised intrcranial pressure on
examination. Cerebrospinal fluid analysis
showed: Cell count 130 /mL (predominantly
lymphocytes), Protein 0.6 g/L, Glucose 3.3
mmol/L, Gram stain showed no organisms.

Which diagnosis is likely?

1- Meningococcocal meningitis

2- Tuberculous meningitis

3- Herpes encephalitis

4- Viral meningitis

5- Aseptic meningitis

[ Q: 755 ] MRCPass - Infectious
disease

Answer & Comments

Answer: 4- Viral meningitis

The combination of lymphocytosis, raised
protein and normal glucose suggests viral
meningitis. Common causes are enterovirus
and mumps

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[ Q: 756 ] MRCPass - Infectious
disease

A 30 year old white woman was referred by
her general practitioner to her local hospital
with a painful vesicular genital rash. On
presentation she was complaining of
headache, neck stiffness, unsteadiness when
walking, double vision, and photophobia.

On admission, she was alert and oriented,
pyrexial (38°C), and hypertensive (blood
pressure 180/80 mm Hg). An extensive
vesicular rash was noted on the posterior
aspect of the right thigh, and bilaterally in the
sacral and perianal areas. There were no
vesicles elsew here. Neurological examination
revealed an intention tremor, marked upper
limb and truncal ataxia and variable
ophthalmoplegia with diplopia and
nystagmus.

Cerebrospinal fluid analysis showed a
predominantly lymphocytic pleocytosis.

What is the likely diagnosis?

1- Pneumococcal meningitis

2- Progressive multifocal

leukoencephalopathy

3- Tuberculous meningitis

4- Meningococcal meningitis

5- HSV encephalitis

Answer & Comments

Answer: 5- HSV encephalitis

In adults HSV-2 usually causes uncomplicated
genital herpes, but occasionally this may
predispose to HSV-2 encephalitis. Neurological
signs vary. MRI can confirm the diagnosis,
demonstrating hyperintensity. Treatment is
with intravenous aciclovir.

HSV encephallitis causing hyperintensity in the

medulla (arrow)

[ Q: 757 ] MRCPass - Infectious
disease

A 30 year old lady presents to renal transplant
clinic with fever and diarrhoea. She is 7 weeks
post live-related-donor transplantation. Her
initial course had been complicated by an
episode of acute rejection which responded to
treatment with anti-thymocyte globulin (ATG).
She is currently maintained on prednisolone,
cyclosporin and azathioprine and has just
finished a course of oral ciprofloxacin for an E.
coli urinary tract infection. Blood tests reveal a
mild hepatitis and leucopenia, and her
creatinine has been rising.

The most likely diagnosis is:

1- Recurrent urinary tract infection

2- Cytomegaloviral infection

3- Graft-versus-host disease

4- Ciprofloxacin toxicity

5- Cyclosporin toxicity

Answer & Comments

Answer: 2- Cytomegaloviral infection

Several weeks post transplantation would be
right for a presentation of cytomegaloviral
(CMV) infection. It is commonest betw een 1-3
months post transplantation and the risk of
severe infection is increased by the use of

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immunosuppressants such as Anti Thymocyte
Globulin.

A number of complications can occur with
CMV infection : pneumonitis, colitis, hepatitis,
retinitis, leucopenia and thrombocytopenia
can occur. Diagnosis can be made by detection
of CMV antigen or with polymerase chain
reaction (PCR) from blood. Tissue biopsy may
show inclusion bodies.

[ Q: 758 ] MRCPass - Infectious
disease

A 44 year old man has arrived from Saudi
Arabia to the UK 5 days ago. He now presents
with painful episodes of trismus. He mentions
he had a cut to his foot while walking barefoot
in his garden 5 days ago. He suddenly has an
episode of generalised tetanus with
respiratory arrest.

Whot should be given to him?

1- IM tetanus antitoxin

2- IV gentamicin

3- PR paracetamol

4- Amputate the foot

5- lonotropes

[ Q: 759 ] MRCPass - Infectious
disease

A 30 year old lady has a mild fever, sore throat
and a erythematous, macular rash develops
on the face giving the appearance of a slapped
cheek. Her child had a similar illness a week
ago. Her blood results are normal.

Which one of the following features is
associated?

1- Renal failure

2- Jaundice

3- Aplastic anaemia

4- Polyarthritis

5- Meningitis

Answer & Comments

Answer: 4- Polyarthritis

Parvovirus infection has an incubation period
of 6 - 14 days. Presentation is usually with a
prodrome of mild fever with a sore throat and
gastrointestinal disturbance which lasts for up
to 4 days. An erythematous rash giving a
slapped cheek appearance is classical.
Polyarthritis and lymphadenopathy are also
associated.

Answer & Comments

Answer: 1- IM tetanus antitoxin

The antibiotic of choice is IV metronidazole. If
he is having generalized spasms he may
require ventilation and muscle relaxants with
or without neuromuscular blockade. IM
antitoxin should be given immediately to
absorb up any unbound tetanus toxin. After
recovery from infection he will still have no
immunity to tetanus and the first dose of
tetanus toxoid is given, with Two further
doses to follow.

[ Q: 760 ] MRCPass - Infectious
disease

A 35 year old woman presented w ith a non¬
healing genital ulcer. She had travelled
through Africa 3 years previously.

On examination, An indurated 1.5 cm ulcer
was present on the inner aspect of the left
labia majoris.

Skin biopsy of the lesion revealed a granuloma
surrounding a schistosome egg. Schistosoma
haematobium eggs were detected in terminal
urine collected betw een midday and 2 pm.

What should she be treated with?

1- Quinine

2- Benzylpenicillin

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3- Tetracycline

4- Flucloxacillin

5- Praziquantel

Answer & Comments

Answer: 5- Praziquantel

Schistosomal infestation may persist and
present long after leaving an endemic area.

Serological tests are the most sensitive
method of screening, but are not species-
specific. Indirect hemagglutination titres ? 64
suggest infection.

Treatment is with praziquantel.

disease that may infect the baby and cause
abnormalities. They may develop congenital
defects, mainly heart defects, deafness and
cataracts (eye lens opacities). The risk drops as
pregnancy advances beyond 20 weeks.

Oral acyclovir is safe in pregnancy. At a later
stage the main danger is that a new born child
would become infected with no transfer of
antibody from the mother. In that case VZig
should be given to the child, but it has no role
in therapy of the mother.

Chickenpox

Schistosomal Egg in the urine

[ Q: 761 ] MRCPass - Infectious
disease

A woman who is 32 weeks pregnant presents
with blistering vesicles present all over her
body. Varicella zoster virus infection is
diagnosed.

How should the patient be treated?

1- Antiretroviral therapy

2- Oral acyclovir

3- Varicella Zoster immune globulin

4- Methylprednisolone

5- Caesarean section

Answer & Comments

Answer: 2- Oral acyclovir

This patient has chickenpox (varicella zoster
infection). In the non-immune pregnant
woman, chickenpox is a potentially dangerous

[ Q: 762 ] MRCPass - Infectious
disease

A 32 year old man has returned from Thailand
4 months ago. He presents with vomiting,
lethargy, myalgia and right upper quadrant
pains. He mentions that whilst he was in
Thailand on holiday, he was treated for severe
falciparum malaria. Investigations show :

ALT 2,100(5-35) U/l
AST 1,700 (1-31) U/l
ALP 350 (20-120) U/l
GGT 70 (4-35) U/l

Bilirubin 320 (1-22) pmol/l
Albumin 30 (37-49) g/l
Glucose 3 mmol/I

What is the likely diagnosis?

1- Falciparum malaria

2- Leishmaniasis

3- Hepatitis B

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4- Dengue

5- Schistosomiasis

Answer & Comments

Answer: 3- Hepatitis B

The incubation period for hepatitis B is 6
weeks to 6 months. The symptoms and
deranged LFTs along with hypoglycaemia
would suggest severe hepatitis and also
seroconversion illness associated with
hepatitis B.

[ Q: 764 ] MRCPass - Infectious disease

An 75 year old man presents to hospital
unwell with diarrhea. He has a BP of 100/70,
heart rate 110 and Temp 38°C. A diastolic
murmur is heard in aortic area.

His bloods show Hb 9.0 g/dl, MCV 85 fl, WCC
13 x 10 9 /L, platelets 270 x 10 9 /l_, urea 6
pmol/l, creatinine 80 pmol/l, sodium 140
mmol/I, potassium 3.8 mmol/I, ESR 80 mm/hr,
CRP 220 mg/I.

Which organism is likely to grow in the blood
cultures ?

[ Q: 763 ] MRCPass - Infectious
disease

A middle-aged, obese man had previously
been treated for chronic venous insufficiency-
related sw elling and cellulitis. He had
hyperpigmentation and hemosiderin
deposition. A further wound swab grew
Pseudomonas aeruginosa.

Which one of the following antibiotics is
recommended?

1- Ciprofloxacin

2- Flucloxacillin

3- Benzylpenicillin

4- Cephalexin

5- Metronidazole

Answer & Comments

Answer: 1- Ciprofloxacin

Pseudomonas can also cause otitis media,
pneumonia (in cystic fibrosis), urinary tract
infection and rarely, endocarditis. Gentamicin,
ciprofloxacin and meropenem are antibiotics
which are effective against pseudomonas
infection.

1- Streptococcus mitis

2- Staphylococcus aureus

3- Streptococcus bovis

4- Escherichia coli

5- Brucella melitensis

Answer & Comments

Answer: 3- Streptococcus bovis

Streptococcus bovis usually enters the
bloodstream via the gastrointestinal tract.
Nearly all patients with S bovis endocarditis
are older than 50 years, and there is also an
association with malignancy of the Gl tract.
Treatment is with penicillin and vancomycin.

[ Q: 765 ] MRCPass - Infectious
disease

A 75 year old woman presented with a non
healing ulcer on her foot. This has been
managed by the podiatrist for the past 8
weeks. Blood cultures and a wound swab both
grew MRSA.

What antibiotics would you consider in
addition to vancomycin?

1- Flucloxacillin

2- Metronidazole

3- Rifampicin

4- Ciprofloxacin

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5- Azithromycin

Answer & Comments

Answer: 3- Rifampicin

For serious infections caused by MRSA strains
that are susceptible to rifampicin, adding this
agent to vancomycin or a fluoroquinolone
may contribute to improved outcomes.
Vancomycin continues to be the drug of
choice for treating most MRSA infections
caused by multidrug resistant strains.

[ Q: 766 ] MRCPass - Infectious
disease

A 50 year old health care worker has been to
India for several months. He was fully
vaccinated prior to travel.

Following return to the UK, a relative notices
that he is yellow. He has a bilirubin of 46
umol/l and ALT of 2500 U/l.

A 30 year old male was readmitted to surgical
ward with history of pain and sw elling in the
left shoulder, following a lipoma removal.
Small vesicles appeared over the left shoulder
and arm.

On examination, patient looked ill, the pulse
rate was 100 beats per minute and blood
pressure was 118/76 mm Hg. X-ray of the left
should and arm revealed diffuse gas bubbles
in the intermuscular tissue planes.

Which one of the following is the most likely
infective organism?

1- Streptococcus pyogenes

2- Neisseria gonorrhoeae

3- Staphylococcus aureus

4- Clostridium perfringens

5- Tuberculosis

[ Q: 767 ] MRCPass - Infectious
disease

Whot is the most likely diagnosis?

1- Hepatitis B

2- Infectious mononucleosis

3- Hepatitis E

4- Yellow fever

5- Leptospirosis

Answer & Comments

Answer: 3- Hepatitis E

Both hepatitis A and E are transmitted by the
faeco-oral route. He is likely to have been
vaccinated against A prior to travel and B in
the context of his occupation. This would lead
to a transient marked transaminitis and
jaundice. The condition should resolve with
conservative management but is associated
with a 1-2% mortality due to the risk of
fulminant hepatitis in patients with underlying
liver disease and pregnant women in the last
trimester in whom the mortality is around
20 %.

Answer & Comments

Answer: 4- Clostridium perfringens

Cases of gas gangrene are known to occur
following trauma and surgical procedures. C.
perfringens is the causative agent of gas
gangrene. Both the enterotoxin producing
strains of Clostridium perfringens and
Clostridium difficile can cause diarrhoea. C.
tetany and C. botulinum form neurotoxins
(Botulism is associated with a flaccid
paralysis).

[ Q: 768 ] MRCPass - Infectious
disease

A 30 year old woman presents with bloody
diarrhoea. The diarrhoea started Two weeks
ago, and was associated with increasing
malaise. There was mild sw elling of the low er
limbs. She has had difficulty passing urine. She
had eaten rare steak during a party recently.
On examination she was pale, and there was

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pressure was 150/95 on admission. On
examination she was apyrexial, but had a
resting tachycardia. There were also crackles
on inspiration at both lung bases.

Investigations show :

Haemoglobin 9 g/dL

White cell count 12.2 x 10 9 /L

Neutrophils 8.7 x 10 9 /L

Platelets 42 x 10/L

blood film may show haemolysis and evidence
of fragmented erythrocytes.

A 45 year old man went on a boat cruise in the
Carribean. Several days later he developed
abdominal cramps and bloody diarrhoea. On
examination, he has a pyrexia Temp 38 C and
generalised tenderness in the lower abdomen.

[ Q: 769 ] MRCPass - Infectious
disease

PT 13 sec

What is the likely cause?

APTT 36 sec

1- Rotavirus

Fibrinogen 5 g/dL

Serum sodium 138 mmol/L

Serum potassium 6.3 mmol/L

2- Sodium monoglutamate excess

3- Entamoeba Histolytica

4- Giardia Lamblia

Serum urea 30 mmol/L
Serum creatinine 426 umol/L
Serum albumin 28 g/L
Dipstick urine Blood ++ Protein +

5- Salmonella species

Answer & Comments

Answer: 5- Salmonella species

What is the most important next investigation
which might yield a diagnosis?

1- Renal tract ultrasound

2- Stool culture

3- Urine microscopy

4- CT scan of the abdomen

5- Echocardiogram

The likely organism from this history causing
bloody diarrhea is Salmonella. Entamoeba is
uncommon around the carribean. Shigella,
salmonella and Campylobacter are all
possibilities which may cause bloody
diarrhoea. Giardia does not usually cause
fevers and rotavirus does not usually cause
bloody diarrhoea.

4 * 1

[ Q: 770 ] MRCPass - Infectious

Answer & Comments

disease

Answer: 2- Stool culture

This patient has haemolytic uraemic syndrome
(HUS). It typically presents with a triad of

acute renal failure, Microangiopathic
haemolytic anaemia, thrombocytopaenia and
deranged clotting. Haemolytic uraemic
syndrome is most commonly a complication of
infection with verocytotoxin producing E.coli
usually of serotype 0157. Stool cultures would
best confirm the diagnosis. In addition, a

A 75 year old man has fevers, neck stiffness
and headaches. He has a past medical history
of polymyalgia rheumatica and has been on
steroids long term. Meningitis is suspected
and a lumbar puncture is performed.

CSF shows protein of 1.2 g/l, glucose 3.4
mmol/l, white cell count 95 (75%

lymphocytes, 20% polymorphs). A few gram
positive rods are seen on microscopy.

What is the likely infective organism?

1- Meningococcus

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2- Mycobacterium tuberculosis

3- Cryptococcus

4- Listeria monocytogenes

5- Staphylococcus aureus

Answer & Comments

Answer: 4- Listeria monocytogenes

The elderly, especially those with
immunocompromise, are prone to Listeria
meningitis. Treatment is with high dose IV
ampicillin or amoxycillin (2g qds).

mortality when inhaled. Ciprofloxacin [400 mg
intravenously (i.v.) 12 hrly] the drug of choice.

Cutaneous Anthrax

[ Q: 771 ] MRCPass - Infectious
disease

A 18 month old child in India has painless
ulcerated lesion over the right buttock of 10
days duration. The infant's mother initially
noticed a papule in that area that increased in
size and ulcerated spon-taneously to form a
blackish eschar. The only other significant
history was the death of a cattle in the
neighborhood.

Cutaneous examination revealed a dark
hemorrhagic eschar surrounded by a zone of
edema and erythema, studded with several
small vesicles that have coalesced.

What is the likely diagnosis?

1- Chickenpox

2- Impetigo

3- Anthrax

4- Tetanus

5- Rabies

Answer & Comments

Answer: 3- Anthrax

This is a case of cutaneous anthrax. Bacillus
anthracis, a spore-forming bacterium, is the
etiologic agent of anthrax. B. anthracis spores
can be aerosolized, are relatively easy to
produce, and are capable of producing high

An asymptomatic 25 year HIV positive male
patient is follow ed up at the clinic.
Investigations reveal a viral load of 270,000
copies/ml and a CD4 count of 190 x 10 6 /ml.

What is the appropriate treatment strategy in
this patient?

1- Start antiretroviral therapy

2- Start antiretrovirals when count < 100

3- Start prednisolone

4- MRI brain

5- Lumbar puncture

[ Q: 772 ] MRCPass - Infectious
disease

Answer & Comments

Answer: 1- Start antiretroviral therapy

Generally, antiretrovrial therapy should be
initiated in asymptomatic patients if a CD4
count betw een 200 to 350 (or less). A HIV
RNA level (viral load) of >30,000 copies/ml
also meets the criteria for starting therapy.

A 30 year old lady has fevers, muscular pains
all over, vomiting and diarrhoea. Her
temperature is 39°C and blood pressure is
85/40 mmHg. There is an erythematous

[ Q: 773 ] MRCPass - Infectious
disease

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desquamating rash in both her hands and legs.
Her tongue is also red.

Which is the likely diagnosis?

1- Toxic shock syndrome

2- Haemolytic uraemic syndrome

3- Disseminated intravascular coagulation

4- Meningococcal sepsis

5- JC virus infection

Answer & Comments

Answer: 1- Toxic shock syndrome

The presentation of pyrexia, shock, diarrnoea
and vomiting, myalgia, desquamating rash and
mucous membrane involvement would be
consistent with toxic shock syndrome. It can
also present with abnormal liver and renal
function, as well as thrombocytopenia. Toxic
shock syndrome can be caused by both
staphylococcus (tampon related) and
streptococcus (skin infection).

[ Q: 774 ] MRCPass - Infectious
disease

A 35 year old man was in South East Asia on
holiday backpacking alone. He has returned 5
days ago, having been there for a month. His
temperature is 38°C and he has a sw ollen
ankle and elbow joint. He also complains of
purulent penile discharge.

Which of the following conditions/infections is
likely?

1- Reiter's syndrome

2- Chlamydia trachomatis

3- Neisseria gonorrhoeae

4- Staphyloccocus aureus

5- Treponema pallidum

This is a typical presentation for gonorrhoeae.
There is penile discharge and knee effusions.
The discharge and knee aspirate may grow
gram negative diplococci. Current
recommended treatment is ceftriaxone 125
mg IM single dose. Concurrent treatment for
chlamydia should be given for 3-6 weeks, to
include oral tetracycline 500 mg 4 times a day
or oral doxycycline 100 mg tw ice a day.

% . * * •

Gram negative diplococci - N. Gonorrhoeae

[ Q: 775 ] MRCPass - Infectious
disease

A 38 year old man with previously treated
early syphilis and hepatitis C infection
presented to a hospital complaining of 3
months of tender right inguinal
lymphadenopathy. An excisional biopsy
showed the formation of necrotising
granuloma indicative of Lymphogranuloma
venereum.

Whot should the patient be treated with?

1- Benzylpenicillin

2- Erythromycin

3- Clindamycin

4- Gentamicin

5- Doxycycline

Answer & Comments

Answer: 5- Doxycycline

Answer & Comments

Answer: 3- Neisseria gonorrhoeae

Confirmation of a diagnosis of LGV requires
serological tests or PCR on genitourinary
specimens. Prolongedtreatment with

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doxycycline or roxithromycin for 3 weeks is
required for affected patients.

Lymphogranuloma venereum

^ Q: 776 ] MRCPass - Infectious
S disease

A 30 year old woman has just given birth to a
baby 2 weeks premature. The baby has a
hypoplastic right eye.

She mentions that early on in the pregnancy
she has a flu-like illness associated with a rash.

What is the probably cause of the congenital
defect?

1- Rheumatic fever

2- Varicella zoster

3- Mycoplasma

4- Toxic shock syndrome

5- Parvovirus B19 infection

Answer & Comments

Answer: 2- Varicella zoster

The patient is likely to have had chickenpox
infection during the second trimester of
pregnancy (risk at this stage = 2% due to limb
development, risk in 1st trimester = 1% unlike
other congenital infections). Rubella infection
of the mother may cause spontaneous
abortion or causes serious damage to the
surviving foetus - characterised by deafness,
blindness and heart defects (risk >90% in 1st
trimester). Parvovirus causes severe anaemia
in the foetus and may result in hydrops
foetalis as a result of heart failure.

[ Q: 777 ] MRCPass - Infectious
disease

J I-

A 42 year old man presented 10 days after
returning from a 8-w eek holiday in South-East
Asia. He had an eight-day history of malaise,
chills, headache, sore throat and generalised
rash. He had reported many mosquito bites.

He had fever, a macular rash and generalised
lymphadenopathy with mild splenomegaly,
but no meningism and no eschar present.

Full blood examination revealed
lymphocytosis with numerous atypical
lymphocytes and thrombocytopenia. Blood
cultures and malaria films were negative. Liver
function tests revealed marginally elevated
serum transaminase levels. Serological testing
revealed past infection with Epstein-Barr virus
and cytomegalovirus and was negative for Q
fever, dengue, rubella, measles and rickettsial
infection.

What is the most likely diagnosis?

1- HIV

2- Dengue fever

3- Syphilis

4- Lyme disease

5- Malaria

Answer & Comments

Answer: 1- HIV

Acute HIV seroconversion may mimic several
tropical diseases, including dengue and
typhus, as well as infectious mononucleosis.

^ [ Q: 778 ] MRCPass - Infectious

| disease

A 25 year old patient was prescribe amoxicillin
for tonsillitis. She goes to see her GP
complaining that she has developed a
maculopapular rash on her trunk and arms.

Which infection is she likely to have?

1- Cytomegalovirus

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2- Tuberculosis

3- Ebstein Barr virus

4- Echovirus

5- Coxsackie virus

Answer & Comments

Answer: 3- Ebstein Barr virus

In glandular fever (EBV infection or infectious
mononucleosis), there is an increased risk of
developing a rash with amoxycillin or
ampicillin. Hence, these antibiotics are
contraindicated.

[ Q: 779 ] MRCPass - Infectious
disease

A 45 year man with alcoholic cirrhosis was
admitted unw ell. He had marked ascites and
a temp of 38°C. An ascitic tap showed a white
cell count of 350 cells per mm3.

[ Q: 780 ] MRCPass - Infectious disease

A 18-year-old man who was previously well
developed an upper respiratory tract infection
follow ed by fever and cough, excessive
sweating and progressive dyspnea. He works
in a factory with humidifiers. One day prior to
admission the patient developed hemoptysis,
left-sided pleuritic chest pain and dizziness.

On examination, the patient was drow sy and
tachypneic. Blood pressure was 130/70
mm/Hg, pulse rate 92/min, respiratory rate
28/min, and temperature 40 C. Chest
auscultation revealed bilateral crepitations in
the low er lung zones. The patient was
commenced on intravenous amoxycillin.

Legionella titer available on the third day was
1:256.

Whot antibiotic should be added?

1- Erythromycin

2- Tazocin

Which of following is the appropriate
antibiotic?

1- Iv cefotaxime

2- Iv metronidazole

3- Iv ciprofloxacin

4- Iv amoxycillin

5- Iv vancomycin

Answer & Comments

Answer: 1- Iv cefotaxime

This lady has spontaneous bacterial peritonitis
(cells >300). The organisms are usually E.

Coli, Pseudomonas, Klebsiella, S Pneumoniae
and Enterococci. Initial treatment should be
broad spectrum such as cefotaxime.
Gentamicin & ampicillin should be considered.

3- Linezolid

4- Rifampicin

5- Gentamicin

Answer & Comments

Answer: 1- Erythromycin

Legionella species can survive for a long
period of time in water and has been found in
moist soil. This may explain the association of
infection with recent excavation, air
conditioner cooling towers, respiratory
devices and humidifiers. A macrolide e.g.
erythromycin is recommmended for
treatment.

[ Q: 781 ] MRCPass - Infectious
disease

A 35 year old patient has a stiff neck, myalgia
and joint pains in the knees, shoulders and
elbows. He had felt that his heart beat was
irregular. He also developed a rash that came
and went on the back over several weeks.

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Which is the best diagnostic test?

1- Monospot test

2- Herpes virus serology

3- Immunofluorescent antibodies to Borrelia
burgdorferi

4- Coxsackie virus serology

5- Serum Anti streptolysin 0 titres

Answer & Comments

Answer: 3- Immunofluorescent antibodies to
Borrelia burgdorferi

This is Lyme disease. It is caused by tick bites
spreading Borrelia burgdorgferi. The rash is
erythema chronicum migrans. Joint pains and
irregular heart beats are common symptoms.
Heart block can occur.

Erythema Chronicum Migrans

^ Q: 782 ] MRCPass - Infectious

S disease

Which one of the following cytokines is
commonly secreted by the T helper 2 cell?

1- IL-1

2- IL-4

3- IL-2

4- TNF alpha

5- IFN gamma

Answer & Comments

Answer: 2- IL-4

TH1 cells commonly secrete IFN gamma and
IL2, leading to B cell, natural killer and
macrophage activation. TH2 cells secrete IL3,
4,5 and 6, leading to mast cells and eosinophil
activation.

A 23 year old student has just returned from
India having been on a holiday. He was bitten
by flies whilst he was there. He has been
lethargic for Two months and has a fever.
Clinical examination reveals

hepatosplenomegaly.

Ultrasound of the abdomen reveals
lymphadenopathy. One of the lymph nodes
are biopsied (a smear shows amastigotes
within a macrophage).

What is the diagnosis?

1- Leishmaniasis

2- Babesiosis

3- Schistosomiasis

4- Malaria

5- Amoebiasis

[ Q: 783 ] MRCPass - Infectious
disease

Answer & Comments

Answer: 1- Leishmaniasis

Leishmaniasis (Kala Azar) is spread by bites
from sandflies. Cutaneous lesions can occur at
the site of the bite. Visceral leishmaniasis can
occur, causing hepatosplenomegaly. The
smears can show Donovan bodies
(amastigotes of Leishmania donovani).

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Three Leishmania amastigotes, each with a
clearly visible nucleus

| *1

A 45 year old man had roast beef lunch on
Sunday. Later that night (about 8 hours later),
he developed abdominal pains and diarrhoea.
On examination, he had a temperature of 37.8
C and generalised abdominal tenderness.

[ Q: 784 ] MRCPass - Infectious
disease

A 55 year old man has a Two week history of
fever, dry cough, central pleuritic chest pain
and breathlessness.

On examination, he has a blood pressure of
110/ 60 mmHg, heart rate of 115 bpm and the
JVP is elevated by 8 cm. Chest X ray shows
pulmonary shadowing. The ECG shows global
ST elevation and T wave inversion.

[ Q: 785 ] MRCPass - Infectious
disease

Stool examination reveals no evidence of
blood.

Which of the following infective organisms is
likely?

1- E coli

2- Shigella

3- Enterovirus

What is the most likely diagnosis?

1- Coxiella pneumonia

2- Coxsackie virus infection

3- Mycoplasma pneumonia

4- Pneumocystis pneumonia

5- Pulmonary tuberculosis

4- Clostridium perfingens

5- Rotavirus

Answer & Comments

Answer: 2- Coxsackie virus infection

Answer & Comments

Answer: 4- Clostridium perfingens

The incubation time of 12-24 hours suggests
that Clostridium perfingens is the most likely
organism. Although the organism is well
known for complications following trauma /
wounds leading to gas gangrene, it can also
cause diarrhoea.

Clostridium perfingens multiplies within the
gut with release of endotoxin during
sporulation. It accounts for about 20% of
bacterial diarrhoea.

Clinically, there is abdominal pain and
diarrhoea, rarely, vomiting, with onset of
symptoms betw een 12 and 18 hours after
incubation, and usually lasting for one day.

Spores are ubiquitous - in animal and human
gut, and the soil. Treatment is conservative for
diarrhoea, but in the case of gas gangrene,
penicillin is the antibiotic of choice.

The pleuritic pains and ECG changes suggests
myocarditis. One of the commonest cause of
this is coxsackie virus.

This may have led to pulmonary oedema, or
even a pericardial effusion causing a raised
JVP.

[ Q: 786 ] MRCPass - Infectious
disease

A 37 year old male who was known to be HIV
positive presents with malaise, and confusion.
His CD4 count measured 1 month ago was 150
x 10 6 /l. There was a witnessed generalized
seizure 12 hours ago. MRI shows multiple ring
enhancing mass lesions in the brain.

What is the treatment of choice?

1- Fluconazole

2- Sulphadiazine and pyrimethamine

3- Rifampicin and pyrazinimide

4- Ceftazidime

5- Prednisolone

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Answer & Comments

Answer: 2- Sulphadiazine and pyrimethamine

Answer & Comments

Answer: 2- Toxoplasmosis

The diagnosis is likely to be cerebral
toxoplasmosis due to the multiple ring
enhancing lesions on CT /MRI scans.

There is an acute onset of focal neurological
deficit over a few days e.g. hemiparesis,
apraxia, visual field defects or cerebellar signs.
Seizures may occur.

There is commonly clouding of consciousness
with fever and constitutional symptoms.
Treatment of choice is with sulphadiazine and
pyrimethamine.

Cerebral Toxoplasmosis causing Ring
Enhancing lesions

[ Q: 787 ] MRCPass - Infectious
disease

A 6 year old child presented for a
comprehensive eye exam. Her mother said
she was born with some type of eye disease
that left her blind in the left eye since birth
and with very poor vision in the right eye.
Dilated fundus exam demonstrated
chorioretinal scars in both eyes.

What is the likely infective diagnosis?

1- CMV

2- Toxoplasmosis

3- Varicella zoster

4- Herpes zoster

5- Meningococcus

Ocular toxoplasmosis results from infection of
the retina by Toxoplasma gondii, an
intracellular parasite that resides in cats'
intestines, undercooked meats or other foods
that contain the tissue cysts, or from mother
to child during pregnancy.The ocular findings
are the most common features of congenital
toxoplasmosis. Affected infants usually are
born with bilaterally healed chorioretinal scars
in the posterior pole.

• 9 4

# y

Fundus showing choroidoretinal scars - Ocular

Toxoplasmosis

[ Q: 788 ] MRCPass - Infectious
disease

A 35 year old lecturer is taken ill on returning
from a 2 week walking holiday around Eastern
Europe. He presents w ith headache, neck
stiffness, photophobia, and right sided Bell's
palsy. He complains of polyarthralgia affecting
shoulders, hips and knees associated with
fever and fatigue for the previous 2 weeks
associated with an urticarial type rash
affecting the right thigh.

What is the diagnosis?

1- Infectious Mononucleosis

2- Rheumatic fever

3- Leishmaniasis

4- Schistosomiasis

5- Lyme disease

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Answer & Comments

Answer: 5- Lyme disease

This patient is presenting in the second stage
of Lyme disease as characterised by the
neurological involvement of his Bell's palsy.
Lyme disease due to Borellia burgdorferi is the
commonest vector bourne disease in the USA
and occurs widely throughout Europe and the
former Soviet Union.

Erythema Chronicum Migrans due to Lyme

disease

Temporal lobe changes on the MRI suggest
that HSV encephalitis is likely. Treatment is
with high dose IV acyclovir 10-15 mg/kg tds.

[ Q: 790 ] MRCPass - Infectious
disease

A 30 year university lecturer develops fevers,
myalgia, lethargy and joint pains over 5 days,
after contact with a colleague with a similar
illness. She has a temperature of 39 °C. On
examination, she has a cheek rash, synovitis of
the hand and knee joints, and palpable lymph
nodes in the cervical area.

What is the likely diagnosis?

1- Infectious mononucleosis

2- Lyme disease

3- Listeriosis

4- Leptospirosis

5- Parvovirus B19

^ Q: 789 ] MRCPass - Infectious

S disease

A 65 year old woman presents with a 2 day
history of fever, generalized headaches and
confusion. An MRI scan shows increased signal
in the right temporo-parietal area. CSF shows
100 white cells (85% lymphocytes), protein
0.65 g/l and an opening pressure of 21 cm.
Glucose is normal. No organisms are seen on
microscopy.

What is the most likely organism?

1- Neisseria meningitidis

2- Herpes Simplex Virus type 1

3- Mycobacterium avium intracellulare

4- Mycobacterium tuberculosis

5- Streptococcus viridans

Answer & Comments

Answer: 2- Herpes Simplex Virus type 1

The fever and confusion suggest encephalitis
and are often accompanied by fitting.

Answer & Comments

Answer: 5- Parvovirus B19

Parvovirus infection or fifth's disease can
cause the 'slapped cheek syndrome'.

There is a cheek rash with sw ollen in the
wrist, hands and knees. Diagnosis can be
confirmed with an IgM antibody to parvovirus
B19.

[ Q: 791 ] MRCPass - Infectious
disease

A 34 year old patient has a CD4+ count of
80/mm. He has had a generalised seizure
recently. An MRI scan is performed, it shows
multiple 1 cm white matter lesions.

Which of these diagnoses is likely?

1- Progressive multifocal

leukoencephalopathy

2- Demyelination

3- Calcified tubers

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4- Behcet's disease

5- Systemic lupus erythematosus

Answer & Comments

Answer: 1- Progressive multifocal

leukoencephalopathy

Progressive multifocal leukoencephalopathy
(PML) is caused by the JC virus, and causes
white matter lesions in the brain. A CD4+ of
90/mm (<400) is low and suggests HIV
infection. Anti-retroviral therapy is the main
treatment for PML.

Multifocal areas of demyelination in PML

[ Q: 792 ] MRCPass - Infectious
disease

A 20 year old student returns from a
backpacking trip in Nepal. He had a 3 week
history of diarrhoea with associated weight
loss. There was no blood in his stools.

Whot is the likely infective organism?

1- Giardia lamblia

2- Shigella flexneri

3- Yersinia enterocolitica

4- Escherichia coli

5- Salmonella typhi

Answer & Comments

Answer: 1- Giardia lamblia

Giardiasis is most likely as it presents as
chronic diarrhoeal illness (without blood) due
to duodenal infestation. The rest of the
organisms cause more acute diarrhoea,

salmonella and shigella diarrhea are
associated with blood.

Giardia

[ Q: 793 ] MRCPass - Infectious
disease

A 30 year old man presents with fevers,
malaise and a cough. There was associated
myalgia. He is a type 1 diabetic. He works in a
water purifier factory, and legionella infection
is supected.

Which of the following tests is most practical
for confirming the diagnosis?

1- Serum Immuno Fluorescent Antibody

2- Sputum Immuno Fluorescent Antibody

3- Sputum microscopy and culture

4- Urinary antigen

5- PCR for legionella DNA

Answer & Comments

Answer: 4- Urinary antigen

The urine antigen test is a rapid, relatively
inexpensive, and practical test for the
detection of L pneumophila antigen excreted
in the urine or present in pleural fluid. Direct
fluorescent antibody (DFA) staining is a rapid
test that can be performed on respiratory
samples and tissue and requires only 2-4
hours for results. It is very specific but not
sensitive, hence a negative result does not
rule out legionella infection. PCR is not widely
available.

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^ [ Q: 794 ] MRCPass - Infectious

0 disease

A 75 year old man presents with sudden onset
of weakness of his right arm on a background
of a 6 week history of lumbar back pain,
weight loss, fever and night sweats.

Blood tests show :

Hb 9.9 g/dL

white cell count 13.5

platelets 470

erythrocyte sedimentation rate (ESR) 100
mm/hr

creatinine 195 micromol/L
calcium 2.45 (2.25-2.7) mmol/l
phosphate 0.22 (0.8-8) pmol/l
IgA 1.3(0.5-4.0) g/l
IgG 14 (5.0-13.0) g/l
IgM 2.7 (0.3-2.2) g/l

Urine dispstick - microscopic haematuria
What is the most likely diagnosis?

1- Endocarditis

2- Secondary syphilis

3- Paget's disease

4- Tuberculosis

5- Myeloma

Answer & Comments

Answer: 1- Endocarditis

disease

A 17-year-old female student from an inner-
city high school presented to her general
practitioner requesting a first prescription for
the oral contraceptive pill. The patient began
sexual activity 6 months previously, had had
five sexual partners and never used condoms.
She had no genital symptoms.

What is a urethral swab most likely to grow ?

1- Syphilis

2- Chlamydia trachomatis

3- Ureaplasma

4- Klebsiella

5- Trichomonas vaginalis

Answer & Comments

Answer: 2- Chlamydia trachomatis

Chlamydia is the commonest organism causing
non gonococcal urethritis.

Urethritis can be caused by a number of
organisms, including Neisseria gonorrheae,
Chlamydia trachomatis, Ureaplasma
urealyticum, Mycoplasma genitalium,
Trichomonas vaginalis, Herpes simplex virus,
and Candida albicans. About half of all men
and three-quarters of all women who have
chlamydia have no symptoms and do not
know that they are infected. Urethritis can
cause dysuria eg. a burning sensaton.
Doxycycline or Azithromycin are the
treatment of choice.

Infective endocarditis with associated
osteomyelitis would explain the clinical
picture of back pains, raised inflammatory
markers and dipstick positive for blood.

The mildly raised immunoglobulins would go
with infection rather than myeloma.

[ Q: 795 ] MRCPass - Infectious

[ Q: 796 ] MRCPass - Infectious
disease

A 25 year old secretary comes to the clinic
complaining of fevers, crampy abdominal
pains and diarrhoea. She has returned from
Turkey on a holiday. Whilst there, she visited
Two spas and spent a long time in jacuzzis.

Which of the following organisms might be
isolated from stool culture?

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1- Vibrio cholerae

2- Cryptosporidium

3- Salmonella

4- Shigella

5- Actinomyces

Answer & Comments

Answer: 2- Cryptosporidium

Cryptosporidium is a protozoan which is
commonly water borne spread. Swimming in
hot tubs and pools, lakes, ponds are risk
factors. It can also be spread via uncooked
food. Treatment is conservative in adults,
whilst the drug nitazoxanide is licensed for
treatment in children age < 12. Symptoms
typically last for 1-2 weeks.

African tick typhus (a form of rickettsial
infection) is characterised by fevers, rash
(which may be maculopapular or petechial)
and an eschar at the site of tick bite (the bite
is often not noticed by the patient). Rickettsial
infection is confirmed serologically with acute
and convalescent titres. Other examples of
rickettsial infection include Rocky Mountain
spotted fever and louse borne typhus. The
treatment of choice is doxycycline.

Eschar of tick typhus

[ Q: 797 ] MRCPass - Infectious
disease

An 18 year old man has recently returned
from Kruger National Park in South Africa. He
has a fever, headaches and arthralgia. He has
a small black ulcer on the inner arm and a
widespread maculopapular rash.

Investigations show :

Hb 11.5 g/l

WBC 6.6 x 10 9 /l_

LDH 680 iu/l

Pits 115 x 10 9 /L

What is the likely diagnosis?

1- Rickettsial infection

2- Malaria

3- Leishmaniasis

4- Schistosomiasis

5- Brucella

Answer & Comments

Answer: 1- Rickettsial infection

A 29 year old banker presents with fever and
loss of weight. He has spent several months
travelling across the countries around Africa
and Asia. He admits that he did not take
malarial prophylaxis. On examination he has
lymphadenopathy and hepatosplenomegaly.
The full blood count shows pancytopaenia.
Aspirates are taken from bone marrow and
Giemsa stained smears of these aspirates
show amastigotes.

Which is the most likely infective organism?

1- Falciparum malaria

2- Leishmania donovani

3- Leishmania major

4- Trypasonoma cruzi

5- Trypasonoma brucei

[ Q: 798 ] MRCPass - Infectious
disease

Answer & Comments

Answer: 2- Leishmania donovani

This patient has clinical features of visceral
leishmaniasis and aspirates have

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demonstrated amastigotes confirming the
diagnosis. Visceral leishmaniasis is caused by
parasites of the Leishmania donovani.

L donovani amastigotes

[ Q: 799 ] MRCPass - Infectious
disease

A 45 year old man has become progressively
more unw ell since return from a business trip
to Ghana 2 days ago.

He had a high fever on admission, but was not
confused. A malarial film shows 12%
parasitaemia with Plasmodium falciparum.

What is the most appropriate treatment
option?

1- Atovaquone

2- Chloroquine

3- Proguanil

4- Quinine

5- Co-trimoxazole

Answer & Comments

Answer: 4- Quinine

In severe falciparum malaria either
intravenous quinine or artesunate should be
administered. Atovaquone is a component of
Malarone (also proguanil) which is liscenced in
uncomplicated falciparum malaria. This
patient may also be considered for exchange
transfusion (considered in parasitaemia >20%
or >10% with organ failure).

[ Q: 800 ] MRCPass - Infectious

disease

A 65 year old man has been admitted to the
ward following a myocardial infarction. He is a
mild diabetic and is hypertensive but both
these conditions are well controlled.

Seven days after admission the patient
develops fever, tachycardia and tachypnoea.
On auscultation of his chest crepitations are
heard over both lung bases. Chest X-ray
demonstrates bilateral basal pulmonary
infiltrates.

Empirical antibiotic treatment for this
condition will be based on the assumption
that the most likely causative organisms are:

1- Gram-negative organisms

2- Staphylococcus aureus

3- Pneumococcus

4- Mycoplasma

5- Neisseria meningitidis

Answer & Comments

Answer: 1- Gram-negative organisms

Gram-negative organisms are the most likely
cause of hospital-acquired pneumonia.
Examples are Klebsiella, Pseudomonas,
Enterobacter, Serratia. Powerful antibiotics
used against these organisms include the
fourth-generation cephalosporins,

carbapenems, ciprofloxacin alone or in
combination with an aminoglycides (entamicin
or tobramycin).

[ Q: 801 ] MRCPass - Infectious
disease

Two days after returning from a 1-week trip
around Thailand, a 30 year old woman
presents with sudden onset of fever,
headache and myalgia. Three days after her
symptoms started she develops a generalized
erythematous rash. Her investigations show :

Hb is 12 g/ dl
WCC 2.2 x 10 9 / I

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platelets 75 x 10 9 / I

What is the most likely diagnosis?

1- Hepatitis C

2- Dengue fever

Mycobacterium bovis infection can be
transmitted from contact with farm animals.
Complications include granulomatous
prostatitis,hepatitis, skin abscess, ureteral
obstruction and epididymoorchitis.

3- Tick-borne encephalitis

4- Syphilis

5- Malaria

Answer & Comments

Answer: 2- Dengue fever

This presentation is typical presentation of
someone with dengue fever which has an
incubation period of 5 to 8 days. Dengue fever
is a condition caused by an RNA virus
(arbovirus), which is common in India, South
East Asia and the Pacific. Spread is by
mosquitos.

A 70 year old white man has spent several
years in Greece where he was exposed to
farm animals and also had a history of
household tuberculosis (TB) contact.

He was referred for pain, sw elling and
decreased function of his left knee prosthesis
which was implanted 5 years ago. The knee
was aspirated and a tissue biopsy was
performed. Sections of soft tissue showed
chronic synovitis with a histiocytic reaction
and a rare focus of epithelioid granulomas.

What organism is likely to be cultured?

1- Staphylococcus aureus

2- Streptococcus faecalis

3- Chlamydia

4- Mycobacterium bovis

[ Q: 802 ] MRCPass - Infectious
disease

Epitheloid granulomas

[ Q: 803 ] MRCPass - Infectious
disease

A 45 year old man has a history of multiple
episodes of sudden, abdominal pain and back
pains.

A haemoglobin electrophoresis shows 95% Hb
S, 4% Hb F, 1% Hb A2. He also has increasing
pain in his right groin radiating to the anterior
aspect of the thigh. His temperature was 38°C.
An X ray reveals irregular bony destruction of
the femoral head.

Which is the most likely organism to be
responsible?

1- Mycoplasma

2- Yersinia pestis

3- Salmonella

4- Candida

5- Moraxella

Answer & Comments

Answer: 3- Salmonella

5- Neisseria gonorrhoeae

Answer & Comments

Answer: 4- Mycobacterium bovis

Salmonella osteomyelitis is frequently seen in
patients with sickle cell anemia. Patients with
sickle cell anemia also exhibit increased
susceptibility to other common infectious

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agents, including Mycoplasma pneumoniae.
Staphylococcus aureus, and Escherichia coli.

A 12 year old girl with sickle cell presents with
abdominal pains and generalised lethargy. On
examination, she w as moderately unw ell and
was noted to be pale. Her temperature was
37°C. Her blood tests show Hb 4.0 g/dl, WCC 4
x 10 9 /L, platelets 50 x 10 9 /L, urea 6 pmol/l,
creatinine 90 pmol/l, sodium 140 mmol/l,
potassium 4.2 mmol/l, bilirubin 28 pmol/l.

Which one of these infections is likely?

1- Hepatitis B

2- CMV

3- EBV

4- Parvovirus B19

5- Polio virus

[ Q: 804 ] MRCPass - Infectious
disease

Answer & Comments

Answer: 4- Parvovirus B19

In sickle cell disease, infection with parvovirus
can cause aplastic anaemia, as seen in this
case, where there is a pancytopenic picture in
the full blood count profile. The condition is
self limiting and the patient may recover
within one to Two weeks.

A 30 year old man presented with bloody
diarrheoa. This started 2 days ago. He
returned from a business trip to Egypt recently
1 week ago.

What is the most likely causative organism?

1- Cholera

2- E coli

3- Giardiasis

4- Shigella

[ Q: 805 ] MRCPass - Infectious
disease

5- Crytosporidiosis

Answer & Comments

Answer: 4- Shigella

The common causes of bloody diarrhoea
include Salmonella , Shigella , Campylobacter
and amoebiasis. E. coli type E 0157 can also
cause bloody diarrhoea with Haemolytic
uraemic syndrome.

A 70 year old man presents to casualty with a
fever and headache. On examination he is
confused, has neck stiffness and a right 6th
cranial nerve palsy. He has no visible rash.

Investigations show :

CSF Protein 3 g/L

CSF Glucose 1.1 (3.3 to 4.4 mmol/l), plasma
glucose 5 mmol/l

CSF Microscopy 350 white cells,
predominantly lymphocytes

Serum VDRL positive and TPHA is negative

The most likely diagnosis is:

1- Meningococcal meningitis

2- Herpes simplex encephalitis

3- Listeria meningitis

4- Lymphocytic meningitis

5- Tuberculous meningitis

Answer & Comments

Answer: 5- Tuberculous meningitis

In TB meningitis, the prodrome is nonspecific,
including headache, vomiting, photophobia
and fever. Cranial nerve palsies can occur. The
duration of presenting symptoms may vary
from 1 day to 9 months. CSF typically shows
elevated protein level, markedly low glucose,
and a pleocytosis, initially polymorphs then
lymphocytes.

[ Q: 806 ] MRCPass - Infectious
disease

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In this case, VDRL may be a sign of previous
syphilis or may be false positive. TPHA is much
more specific, hence since it is negative in this
case, syphilis infection is unlikely.

The best antimicrobial agents in the treatment
of TBM include isoniazid (INH), rifampicin
(RIF), pyrazinamide (PZA), and streptomycin
(SM), all of which enter CSF readily in the
presence of meningeal inflammation.
Ethambutol (EMB) is less effective in
meningeal disease unless used in high doses.

[ Q: 808 ] MRCPass - Infectious disease

A 40 year old lady presents with a cellulitis in
the left leg. She had a laceration to the area 3
days ago. Blood cultures grow a gram-negative
rod subsequently identified as Pasteurella
multocida.

What was the most likely cause of the
penetrating injury?

1- Snake bite

2- Cat bite

[ Q: 807 ] MRCPass - Infectious
disease

A 45 year old patient presents with
meningism. There is no past medical history.
CT scan was normal and he had the following
CSF results:

3- Spider bite

4- Bee sting

5- Scorpion bite

Answer & Comments

Answer: 2- Cat bite

150 X 10 6 /ml white cells (90% lymphocytes)
protein was 6g/l
glucose 2.2 mmol/I

Microscopy revealed no gram positive
organisms and no Acid fast bacilli were seen.

Which is the next best test?

1- TB PCR of the cerebrospinal fluid

2- CSF cytology

3- Heaf test

4- Herpes viral serology

5- Blood cultures

Answer & Comments

Answer: 1- TB PCR of the cerebrospinal fluid

A CSF lymphocytosis and low glucose points
tow ards TB meningitis.

Despite no AFBs being seen, the TB PCR is a
rapid way to confirm his diagnosis definitively.

Pasteurella multocida is found in the snouts of
both dogs and cats. Soft tissue infection
results following bites and may progress to
tenosynovitis, osteomyelitis or lymphangitis
depending on the site of the bite. Drug
therapy is with penicillin.

[ Q: 809 ] MRCPass - Infectious
disease

An 18 year old man has been working on a
farm during the summer holidays from
university. He is now unwell.

On examination his BP is 115/65 mmHg and
temperature is 38 C. He has jaundice and mild
hepatosplenomegaly.

Blood tests reveal: Hb 13.5 g/dl, WCC 11.2 x
10 9 /L, platelets 225 x 10 9 /L, sodium 137
mmol/I, potassium 4.2 mmol/I, urea 14
pmol/l, creatinine 180 pmol/l.

Which test is most likely to reveal the
underlying diagnosis?

1- Brucella antibodies

2- Paul Bunnell test

3- Leptospira antibodies

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4- MRI to look for cystic lesions

5- HIV test

Answer & Comments

Answer: 3- Leptospira antibodies

Leptospirosis is spread by rodents, those at
risk are farmw orkers and those working at
sewers. It can lead to fevers, jaundice,
haemoptysis and renal impairment. The
diagnosis is confirmed by dark field
microscopy of urine and serologically.

5- Pneumocystis pneumonia

Answer & Comments

Answer: 5- Pneumocystis pneumonia

The diagnosis is pneumocystis pneumonia. HIV
infection is suggested by the low white cell
count and oral candidiasis. Dry cough, fever
and tachypnoea are typical in PCP. The
organism lies in the alveolar space (foam),
causing hypoxia and a low transfer factor.
Typically there are no crackles, although it
may occasionally be present.

Spiral shaped Leptospira interrogans

Pneumocystis pneumonia

^ [ Q: 810 ] MRCPass - Infectious

fjt disease

\%\

• i j

i_?

[ Q: 811 ] MRCPass - Infectious

A 45 year old African American male presents

disease

with sudden-onset chest pain which he
associated with a high fever, dry cough, and
shortness of breath. He was found to have low
oxygen saturation betw een 80-90%. Oral
examination revealed moist mucosa but mild
thrush was noted on tongue. Respiratory
exam showed fine crackles in low er one-third
of bilateral bases.

A chest X-ray revealed prominent interstitial
markings. Blood tests reveal a white cell count
of 3 x 10 9 /L.

Whot is the likely diagnosis?

1- Asthma

2- Allergic Bronchopulmonary Aspergillosis

3- Legionella Pneumonia

4- Histoplasmosis

A 30 year old lady presents with headache and
neck stiffness. Her temperature is 38.5°C, BP
100/65 and she has a petechial rash in the
thigh. CSF examination reveals gram negative
diplococci.

Which is the best antibiotic therapy?

1- Gentamicin

2- Flucloxacillin

3- Cefuroxime

4- Ciprofloxacin

5- Benzylpenicillin

Answer & Comments

Answer: 5- Benzylpenicillin

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The diagnosis is meningococcal meningitis (it
would be pneumococcal meningitis if gram
positive diplococci were seen). Intravenous
ceftriaxone or benzylpenicillin are treatment
of choice.

Meningococcal Rash

[ Q: 812 ] MRCPass - Infectious
disease

A 32 year old woman was admitted to hospital
with cough and breathlessness. She had been
well until two w eeks previously, when she
developed headache and nausea followed by
a cough. Her general practitioner prescribed
amoxycillin with clavulanic acid on the day of
admission. She had no history of foreign travel
and kept no pets.

On admission she was unw ell and pyrexial.
The main abnormal signs were a raised heart
rate (140 beats/min),

and respiratory rate (32 breaths/min). There
were left basal crackles. Chest x ray showed
mild shadowing.

Which one of the following tests should be
sent for making a diagnosis of legionella
infection ?

1- Serum immunofluorescent antibody

2- Sputum immunofluorescent antibody

3- Sputum culture

4- Urinary antigen

5- Blood cultures

Answer & Comments

Answer: 4- Urinary antigen

The urine antigen test (a radioimmunoassay)
is a rapid, relatively inexpensive, and practical
test for the detection of L pneumophila
antigen excreted in the urine or present in
pleural fluid.

[ Q: 813 ] MRCPass - Infectious
disease

A 60 year old man presented with fatigue. He
gave a history of Two similar episodes of
extreme fatigue in the past five years. During
one of these episodes, elevated liver enzymes
were found. An examination showed that he
was otherw ise healthy. He was not on
medications, and he denied drinking. He had
no known family history of liver disease.

Laboratory Results:
AST: 349 U/l
ALT: 452 U/l

Total bilirubin: 70 umol/l

HBsAg: positive
Anti-HCV: negative

After several months, he was follow ed up by
a gastroenterologist, his symptoms had
resolved. Repeat testing at this time showed
the following:

Laboratory Results:

AST: 55U/I

ALT: 68 U/l

Total bilirubin: 25 umol/l
HBeAg: negative
Anti-HBe: positive
HBV DNA: 125,000 copies/mL
What is the diagnosis?

1- Superimposed hepatitis E

2- Superimposed hepatitis D

3- Acute antigen negative hepatitis B

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4- Chronic antigen negative hepatitis B

5- Hepatitis B in remission

Answer & Comments

Answer: 4- Chronic antigen negative hepatitis
B

This is a case of patients with E-antigen
negative chronic Hepatitis. Despite E-antigen
being negative, these patients can continue to
have active HBV DNA level and active liver
disease.

^ Q: 814 ] MRCPass - Infectious
0 disease

A 52 year man enquired about whether it was
advisable to have vaccination prior a holiday
abroad. He had asthma treated with long term
steroids. Frequently, courses of Prednisolone
in excess of 30mg daily were given.

Which one of the following vaccinations is
contraindicated in the patient?

1- Hepatitis B

2- Diphtheria toxoid

3- Yellow fever

4- Meningococcus

5- Tetanus toxoid

Answer & Comments

Answer: 3- Yellow fever
The live vaccines are:

■ BCG

■ Mumps

■ Measles

■ Rubella

■ Yellow fever
Smallpox

[ Q: 815 ] MRCPass - Infectious

disease

An 60 year lady has a 3 month history of dry
cough. She feels sw eaty at night. Her
temperature is 39 C and chest X ray shows a
cavitating lesion in the right upper lobe.
Induced sputum was attempted but was
unsuccessful.

Which of the following investigations would be
useful in establishing the cause of this lesion?

1- CT of the chest

2- Ultrasound of the lesion

3- Bronchoscopy

4- Aspergillus serology

5- Percutaneous biopsy

Answer & Comments

Answer: 3- Bronchoscopy

This patient is likely to have tuberculosis, but
induced sputum has been unsuccessful to
send for AFBs. The best way of obtaining a
diagnosis is to get a bronchoscopy with
bronchial washings to send for TB culture.

A 35 year old female is referred due to
positive serology for syphilis. She gives a
history of treatment for syphilis 5 years ago.
Tests show a positive venereal disease
reference laboratory (VDRL) titre of 1:128 and
a positive Treponema pallidum
haemagglutination assay (TPHA) titre of
1:1024.

Which of the following explanations is most
consistent with these data?

1- Tertiary syphilis

2- Active syphilis reinfection

3- Inadequate previous treatment

4- Pregnancy

5- Superimposed gonorrhoea treatment

[ Q: 816 ] MRCPass - Infectious
disease

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Answer & Comments

Answer: 2- Active syphilis reinfection

Successful therapy for syphilis leads to a
steady fall in the VDRL or rapid plasma reagin
(RPR) titre. Following primary disease the
VDRL is generally negative within 1 year, and
within 2 years for secondary syphilis. A small
number of treated patients have a persistently
low detectable VDRL.

This patient's high VDRL titre of 1:128 most
likely represents recent acquisition of
infection - within the past 12 months.

A 40 year old man presented 14 days after
return from a 6-w eek field trip to Papua New
Guinea. He had a six day history of high fevers
and rigors. On the day of presentation, he had
become vague and confused. He had taken
antimalarials as prophylaxis, but ceased when
he found that local people did not take them.

His temperature was 40oC, pulse rate 140
bpm, respiratory rate 28 per minute, and
blood pressure 100/60 mmHg.

He had dry mucous membranes, mild
jaundice, pallor, splenomegaly and
generalised crackles in both lungs.

Full blood examination revealed:

6.5 g/dL

WCC 2.5 x 10 9 /L

Platelet 10 x 10 9 /L

bilirubin 60 pmol/L (3-20 pmol/L)

lactate dehydrogenase 489 U/L (100-225 U/L)
creatinine 250 umol/l

What is the likely diagnosis?

1- Leishmaniasis

[ Q: 817 ] MRCPass - Infectious
disease

2- Tick bite fever

3- Endocarditis

4- Falciparum malaria

5- Viral haemorrhagic fever

Answer & Comments

Answer: 4- Falciparum malaria

This patient has severe malaria suggested by
altered consciousness, focal neurological
signs, jaundice, oliguria, severe anaemia,
hypoglycaemia, hypotension and acidosis.

Severe malaria requires treatment with
intravenous quinine.

P. falciparum rings in erythrocytes

A 62 year old woman was admitted to the
emergency department with deterioration in
her level of consciousness. On examination,
her pupils were equal and reactive, Kernigs
and Brudzinski's signs were positive.

Investigastions showed:

CT scan of the head - cerebrovascular disease.

Lumbar puncture was performed and this
showed an opening pressure > 25 cmH 2 0.

CSF showed a white cell count in
cerebrospinal of 133 (all polymorphs), red
blood cell count of 25 (no xanthochromia),
and protein level of 0.75 g/l. Glucose 2.5
mmol/l.

[ Q: 818 ] MRCPass - Infectious
disease

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Which is the likely causal organism ?

1- Listeria monocytogenes

2- Streptococcus pneumoniae

3- E coli

4- Klebsiella

5- Pseudomonas aeruginosa

Answer & Comments

Answer: 2- Streptococcus pneumoniae

The commonest cause of bacterial meningitis
in the elderly is Strep pneumoniae. The CSF
glucose is only slightly low and hence is not
consistent with TB meningitis.

[ Q: 819 ] MRCPass - Infectious
disease

A 35 year old man develops a fever 7 days
post bone marrow transplantation. He is
placed empirically on Cefuroxime but remains
febrile. After a few days, he develops a few
painless, red, papular lesions on his trunk and
lower limbs.

Investigation results are:

Hb 10.5 g/dl
MCV 87 fl

WCC 18 x 10 9 /L (50% lymphocytes)

platelets 130 x 10 9 /L

ALT 130 (5-35) U/l

AST 95 (1-31) U/l

ALP 140(20-120) U/l,

Bilirubin 35 (1-22) pmol/l

Albumin 36 (37-49) g/l

What is the likely cause of these lesions?

1- Stevens Johnsons syndrome

2- Staphylococcal infection

3- Candidal infection

4- Graft versus host disease

5- Aspergillus infection

Answer & Comments

Answer: 4- Graft versus host disease

The presentation of acute graft versus host
disease is often a triad of dermatitis, hepatitis,
and gastroenteritis, although symptoms may
occur alone or in different combinations.

Maculopapular rash may present with the
onset occurring within 5-47 days after
transplantation. Pruritus involving the palms
and soles may precede the rash.

Anaemia and thrombocytopenia are common.
The liver is the second most common organ
involved. GVHD also manifests as elevated
liver transaminases levels. Cholestatic
jaundice is common.

Successful therapeutic intervention of life-
threatening GVHD is possible, although the
consequence can be the development of fatal
opportunistic infections. Therefore, the best
approach to manage GVHD should be its
prevention.

Maculopapular rash seen in Graft versus Host

Disease.

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[ Q: 820 ] MRCPass - Infectious
disease

A 31 year old patient who is HIV positive has a

CD4 count of 200 cells /mm * 1 2 3 4 5 . He has a viral

load of 220,000 cells/ml. He is feeling well at

present.

Whot should be the next management step?

1- Start antiretroviral therapy now

2- Start antiretroviral therapy when viral load
is > 300,000 cells/ml

3- Start antiretroviral therapy when CD4 count
is < 100

4- Start antiretroviral therapy when CD4 count
is < 150

5- Start antiretroviral therapy when patient is
symptomatic

Answer & Comments

Answer: 2- Trophyrema whippelli

Whipple's disease typically presents as a
gastrointestinal illness caused by the organism
Tropheryma whippelli. The illness is
characterized by diarrhea, abdominal cramps,
and sometimes frank malabsorption. If
gastrointestinal disease is prominent,
duodenal biopsy is performed, it often yields
evidence of Trophyrema whippelli by light
microscopy, electron microscopy, or PCR,
allowing the diagnosis to be substantiated.

Histopathologically, one sees macrophages
containing periodic acid-Schiff (PAS)-positive
material. The characteristic rod-shaped
intracellular organism is seen by electron
microscopy.

Answer & Comments

Answer: 1- Start antiretroviral therapy now

The general recommendation for considering
HAART and best prognosis is to they start
when patients' CD4 count is <200 cells/mm 3 or
viral load is >10,000 cells/mL.

[ Q: 821 ] MRCPass - Infectious
disease

A 45 year old man presents with malaise,
weight loss and diarrhoea. On examination his
skin is pigmented, his fingers are clubbed.
There is cervical and axillary
lymphadenopathy. Upper gastrointestinal
endoscopy is performed and distal duodenal
biopsies demonstrate stunted villi. The lamina
propria is distended with multiple periodic
acid-Schiff (PAS) positive macrophages.

The aetiological organism is:

1- Mycobacterium tuberculosis

2- Trophyrema whippelli

3- Candida albicans

4- Giardia lamblia

5- Amoeba

Current recommendations are for a tw o-w
eek course of intravenous ceftriaxone, to be
followed by one to two years of double¬
strength oral trimethoprim-sulfamethoxazole.

Periodic acid-Schiff (PAS) stain reveals
intensely PAS positive rod shaped and
granular inclusions in macrophages

[ Q: 822 ] MRCPass - Infectious
disease

A 42 year old patient with hepatitis B infection
is being considered for therapy in outpatients.

Which antiretroviral is also used for the
therapy of hepatitis B virus (HBV) infection?

1- Lamivudine

2- Zidovudine

3- Nevirapine

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4- Indinavir

5- Saquinavir

Answer & Comments

Answer: 1- Lamivudine

Lamivudine (3TC) is a nucleoside analogue
that inhibits viral DNA synthesis. Those who
benefit the most from treatment are chronic
hepatitis B infected patients with persistently
elevated transaminases who are actively
replicating virus (with viral DNA testing
positive) and have evidence of chronic
hepatitis on liver biopsy. Lamivudine may also
be used to suppress hepatitis B infection in
patients undergoing liver transplantation or
others where immunosuppression is required.
Alpha Interferon is the other drug which is
currently used to treat hepatitis B.

A 32 year old man is referred following a 6
month history of confusion. He is depressed
and has frequent mood swings. He also has
recurrent, asymetrical, jerks in all 4 limbs.

Which of the following investigations is most
likely to be useful in reaching a diagnosis?

1- CT head

2- EMG

3- Chest X Ray

4- Inflammatory markers

5- EEG

[ Q: 823 ] MRCPass - Infectious
disease

Answer & Comments

Answer: 5- EEG

sporadic CJD may show significant
abnormalities involving deep brain areas
(thalamus) with diffuse, nonspecific changes,
developing into stereotyped high voltage
components on a slow backgound.

A 35 year old man has returned from a field
trip in Malaysia. He now has a fever of 39°C,
headache, muscular aches and pains.
Examination reveals an erythematous rash on
his abdomen and thighs. There was cervical
and inguinal lymphadenopathy.

Blood tests show :

Hb 14.0 g/dI

MCV 80 fl

WCC 7 x 10 9 /L

platelets 120 x 10 9 /L

urea 7 pmol/l

creatinine 100 pmol/l

sodium 142 mmol/l

potassium 4.2 mmol/l

bilirubin 16 pmol/l

AST 120 U/l

ALP 1500 U/l

albumin 32 g/l

ESR 60 mm/hr

CRP 180 mg/I

Which of the following infections is likely?

1- Syphillis

2- Chlamydia

3- Dengue fever

[ Q: 824 ] MRCPass - Infectious
disease

The presentation of rapid cognitive decline in
a young person with myoclonus is suggestive
of Creutzfeld Jakob disease. This may be new
variant (in which the EEG is often normal) or
sporadic (in which case characteristic EEG
abnormalities may be expected). The EEG in

4- Yellow fever

5- Typhoid fever

Answer & Comments

Answer: 3- Dengue fever

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Dengue fever caused by an arthropod borne
flavivirus (typically the Aedes mosquito
insect). It is present in South East Asia, Africa,
Middle East and India. The disease has an
incubation period of 7 days. Headaches, retro-
orbital pain, musculoskeletal pains and a
maculopapular rash can occur. Treatment is
conservative with antipyretics and bedrest.

[ Q: 825 ] MRCPass - Infectious
disease

An 18 year old girl was studying for
examinations together with a friend who was
hospitalised 2 days ago with meningitis. The
blood cultures in her friend grew
meningococcus group A.

Which of the following actions should be token
towards the girl who was in contact with the
patient?

1- Immunisation with meningococcus A
vaccine

2- Immunisation with meningococcus A and C
vaccine

3- Immunisation with meningococcus A and C
vaccine, and rifampicin

4- Rifampicin only

5- Full treatment for meningitis A

Answer & Comments

Answer: 3- Immunisation with meningococcus
A and C vaccine, and rifampicin

Immunisation is available against strains A and
C of this bacteria, however strain B is the most
often implicated in meningococcal meningitis.
Due to close contact, this girl should be given
both available vaccines and also rifampicin.
Apart from rifampicin, minocycline and
ceftriaxone can also be used for prophylaxis.

A 45 year old pig farmer is admitted to A+E
following Two generalised seizures. He has no
significant neurological history. On
examination, he had no focal neurological
signs. A CT scan of the head shows
periventricular cystic lesions. There is
eosinophilia of 10%.

Which of the following infective organisms is
likely?

1- Toxocara canii

2- Ascaris lumbricoides

3- Schistosoma mansoni

4- Yersinia enterolitica

5- Taenia solium

[ Q: 826 ] MRCPass - Infectious
disease

Answer & Comments

Answer: 5- Taenia solium

Toxocariasis is commonly passed on from dog
and cat faeces. Ascariasis is roundw orm
infection which commonly causes abdominal
symptoms. Yersninia is a bacterial infection
spread from half cooked meat and
unpasteurised milk, causing abdominal
symptoms and diarrhoea. Taenia solium is the
pork tapeworm which causes the condition
cysticercosis described above. Cysts are
commonly found in the brain and seizures are
common.

Taenia Solium

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A 55 year old man has lived in Saudi Arabia for
several years but moved to the UK. He
presents with severe right hypochondrial pain,
nausea, vomiting, fever, cough and chest pain
of one day duration.

Physical examination revealed tachypnoea,
tachycardia and a temperature of 39 C. Chest
examination showed dullness, diminished air
entry and bronchial breathing in the right low
er zone of the chest posteriorly. There were
tenderness and guarding in the right upper
quadrant of the abdomen and the right low er
intercostal spaces.

A chest x ray showed consolidation of the
right low er lobe of the lung with pleural
effusion. Abdominal ultrasound several cystic
lesions in the liver.

What is the likely diagnosis?

1- Polycystic liver diseaes

2- Hydatid disease

3- Tuberculosis

4- Sarcoidosis

5- HIV infection

Answer & Comments

Answer: 2- Hydatid disease

Hydatid disease due to Echinococcus
granulosusis (found in in cattle-and
sheepraising regions) of the world such as
Central Europe, the Mediterranean countries,
the Middle East, South America, and South
Africa. Hydatid cysts are known commonly to
affect the liver and lung.

The treatment of hydatid cysts is surgical. Pre-
and post-operative 1-month courses of
Albendazole and 2 weeks of Praziquantel
should be given.

[ Q: 827 ] MRCPass - Infectious
disease

Hydatid cysts in the liver

[ Q: 828 ] MRCPass - Infectious
disease

A 28 year old man has recently been
diagnosed as HIV-positive. In view of a high
viral load and low CD4 count he w as
commenced on septrin (960 mg alternate
days), Zidovudine 250 mg b.d., Lamivudine
150mg b.d. and Abacavir 300mg b.d. 8 weeks
into this regimen he becomes progressively
unw ell over 3 days - he develops a pyrexia of
40°C, an erythematous macular rash affecting
the limbs and trunk, nausea, vomiting and
abdominal pains. He has also become
significantly more breathless this evening.

What immediate course of action is advisable?

1- Stop zidovudine

2- Initiate steroids

3- Stop septrin

4- Stop abacavir

5- Stop lamivudine

Answer & Comments

Answer: 4- Stop abacavir

Abacavir hypersensitivity occurs in 5% of
individuals. It may present without a rash and
should be considered in the differential
diagnosis of any febrile illness after
commencing abacavir. Abacavir should be
stopped and an alternative anti-retroviral
agent commenced to maintain triple
combination therapy.

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[ Q: 829 ] MRCPass - Infectious
disease

A 40 year old man has spent a year in South
America working in the computer industry. He
develops fevers, night sw eats, vomiting and
pain in the right upper quadrant. Blood tests
reveal a raised white cell count but not
eosinophil count. An CT of his abdomen shows
a large cyst.

Which is the best treatment?

1- Hepatectomy of hepatoma

2- Surgical removal of aspergilloma

3- Albendazole for hydatid cyst

4- Metronidazole for amoebic liver abscess

5- Quadruple therapy for TB

Answer & Comments

Answer: 4- Metronidazole for amoebic liver
abscess

Amoebiasis is caused by Entamoeba
histolytica is spread by faeco oral route. It can
present months or a year after infection. RUQ
and referred pain to the shoulders as well as
with systemic symptoms are common
presentations.

[ Q: 830 ] MRCPass - Infectious
disease

A 78 year old woman who is resident in a
nursing home has been treated by her GP for
pneumonia 2 weeks ago, and now presents
with diarrhea and abdominal pains. The
diarrhoea is occuring 8 times a day and has a
greenish colour.

What is the best treatment for her?

1- Metronidazole

2- Ciprofloxacin

3- Gentamicin

4- Erythromycin

5- Tazocin

Answer & Comments

Answer: 1- Metronidazole

The diagnosis is likely to be
pseudomembranous colitis. C. difficile toxin
should be sent off. As the index of suspicion is
high, she should be given metronidazole.

[ Q: 831 ] MRCPass - Infectious
disease

A 40 year old woman in otherw ise good
health, was cleaning debris on her land and
was exposed to animal feces. The patient was
removing rocks when she accidentally grasped
a piece of barbed wire concealed by the
murky water. This led to four cuts to the
palmer surface of four fingers on her right
hand. She cleaned the injury w ith an
antibacterial soap and immediately continued
working.

Seven days later, she presented to the
emergency room (ER). left side of her jaw
became painful and badly sw ollen. She had
inability to open her mouth, and difficulty
breathing.

What is the most likely infective organism?

1- Clostridium tetani

2- Rabies virus

3- Ross River virus

4- Staphylococcus aureus

5- Streptococcus pyogenes

Answer & Comments

Answer: 1- Clostridium tetani

Tetanus, sometimes known as lockjaw is a
disease manifested by uncontrolled spasms,
due to the introduction of Clostridium tetani
toxin into tissues. Skin punctures,
contaminated wounds with soil, dust, burns
have a role in the development of the disease.

The spores produce a neurotoxin
(tetanospasmin) which causes severe spasm

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all over the body leading to painful muscle
contraction and laryngeal spasm which
interfere with breathing and muscle tears.

syndrome. Clindamycin has effects of reducing
protein synthesis and exotoxin production by
the bacteria.

The incubation period is typically between 1-2
weeks. Vaccination with tetanus toxoid has
been proved to be effective. Booster
immunization to whose who have been
injured is advisable, especially for those whose
last immunization received was 10 years or
more. The conventional treatment of severe
tetanus which is supportive along with
penicillin, is still the most effective treatment.

Risus sardonicus is an abnormal, sustained
spasm of the facial muscles that is most often
observed as a symptom of tetanus. Trismus is
a pathological, sustained spasm of the neck
and masseter (jaw) muscles that can make it
difficult or impossible to open the mouth, also
most often associated with tetanus.

A 40 year old diabetic lady presents with a hot
swollen left leg. On examination has a
temperature of 39°C and her leg is tender to
compression. She was treated with
intravenous flucloxacillin and benzylpenicillin.
However, the erythema has spread even
further after 3 days, she is persistently
hypotensive with a systolic BP of < 90 mmHg.

Which of the following antibiotics should be
added?

1- Gentamicin

2- Tazocin

3- Chloramphenicol

4- Clindamycin

5- Amoxycillin

[ Q: 832 ] MRCPass - Infectious
disease

Answer & Comments

Answer: 4- Clindamycin

[ Q: 833 ] MRCPass - Infectious
disease

A 35 year old man has travelled to South East
Asia 2 weeks ago. He presents to the hospital
with fevers, diffuse rash and lethargy.

The rash was a widespread maculopapular
rash affecting the palms of his hands and soles
of feet. There was also a rash on the face,
mouth ulcers and exudative pharyngitis.

He also had several raw, red, mouth ulcers.

What is the most likely infection?

1- Measles

2- Lyme disease

3- HIV

4- Syphilis

5- Tuberculosis

Answer & Comments

Answer: 3- HIV

Both seroconversion of HIV and secondary
syphilis are possibilities. How ever,
seroconversion can occur in 2 - 4 weeks of
infection, but secondary syphilis usually occurs
2-4 months after. Primary syphilis w ould
present within 2 weeks with a chancre.

Rash in seroconversion illness

There is suspicion that this lady may have
Streptococcus A infection with toxic shock

[ Q: 834 ] MRCPass - Infectious

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disease

A 45 year old man presented with a cough and
night sw eats. He had CXR changes showing
upper zone fibrosis.

Chemotherapy was commenced (rifampicin,
isoniazid and pyrazinamide ). Two weeks later
he develops stridor.

Repeat CXR shows enlarged hilar lymph nodes
compressing on the bronchi.

Which is the best management strategy?

1- Add ethambutol

2- Mediastinoscopy

3- Surgical decompression

4- Dapsone

5- Prednisolone

Answer & Comments

Answer: 5- Prednisolone

The patient has mediastinal lymphadenitis
with evidence of bronchial compression.

What is the most likely diagnosis?

1- Smallpox

2- Chickenpox

3- Influenzae

4- Icthyosis

5- Shingles

Answer & Comments

Answer: 1- Smallpox

Chickenpox, which is the more common
disease, causes a rash which is typically
central, and does not affect the hands and
feet.

The smallpox rash is more distal and causes
deep lesions which leave scars. The criteria for
smallpox include:

(1) a centrifugal distribution of lesions, with
the first lesions on the oral mucosa or palate,
face, or forearms

(2) a toxic or moribund appearance

Steroids are highly effective in reducing
lymphadenopathy in this situation and should
be the first option.

(3) the slow evolution of lesions of 1-2 days
per stage

(4) lesions that appear on the palms and soles

[ Q: 835 ] MRCPass - Infectious
disease

A 35 year old man is unw ell and comes to the
hospital. He complains of a headache and
backache that started suddenly the previous
afternoon with fever and chills.

His temperature is 39 C, heart rate is 100/min,
respiratory rate is 20/min, and blood pressure
is 110/70 mm Hg.

On examination, he is unw ell. There are
several small erythematous macular lesions on
the oral mucosa. There are also small vesicles
with the majority on his face, forearms, palms,
and legs consistent with a centrifugal rash.

They appear to be deeply embedded and firm.
A few lesions are on his trunk.

Smallpox is caused by the variola virus (genus
Orthopoxvirus). Patients exposed to the most
common form of smallpox, variola major, will
have a symptom-free incubation period of 7-
17 days, with an average of 12 days.

Smallpox rash

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[ Q: 836 ] MRCPass - Infectious
disease

A 55 year old woman has recently travelled to
Spain and developed watery diarrhoea.

Which of the following is the commonest
world wide couse of traveller's diarrhoea?

1- E coli

2- Giardia

3- Shigella

4- Salmonella

5- Campylobacter

Listeria can cause disease in the
immunosuppressed (including pregnant
women). Ampicillin is the drug of choice to
cover listeria in addition to ceftriaxone (which
covers strep pneumoniae and meningococci).

[ Q: 838 ] MRCPass - Infectious
disease

A 60 year old woman who had a long history
of alcohol abuse presents with diarrhoea and
back pain. She had recently had an iv cannula
for a drip following a drunken episode. On
examination she had a fever of 39°C.

Answer & Comments

Answer: 1- E coli

Traveller's diarrhoea is an extremely common
occurrence, affecting up to half of travellers to
high risk areas such as Africa, Asia and South
America. The commonest infective cause
world-w ide is Escherichia coli. Other bacterial
causes include Shigella, Salmonella and
Campylobacter, all of which can cause
dysentery (diarrhoea with blood).

[ Q: 837 ] MRCPass - Infectious
disease

A lady who is 25 years of age, presents with a
headache, neck stiffness and photobophia.
She was been treated with ceftriaxone, and
also with ampicillin added.

What organism is ampicillin intended to cover
in this case?

1- Klebsiella

2- Meningococcus group B

3- Meningococcus group C

4- Listeria

5- Enterococci

Answer & Comments

Answer: 4- Listeria

What is the likely diagnosis?

1- Endocarditis

2- Pancreatitis

3- Staphylococcal discitis

4- Diverticulitis

5- Subacute bacterial peritonitis

Answer & Comments

Answer: 3- Staphylococcal discitis

Staphylococci are skin organisms which can be
introduced insertion of lines (cannulas or
central lines). This may lead to discitis which
can cause back pain or endocarditis (which
would present differently).

A 45 year old man presents 2 weeks after
returning from a holiday in Tanzania. He has a
serpiginous rash on the finger and a low -
grade fever.

Which of the following is the most likely
diagnosis?

1- Group-A Streptococcal infection

2- Cutaneous myiasis

3- Cutaneous larval migrans

4- Rickettsial chancre

[ Q: 839 ] MRCPass - Infectious
disease

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5- Trypanosomal chancres

Answer & Comments

Answer: 3- Cutaneous larval migrans

Cutaneous larva migrans, caused by various
Ankylostoma (hookw orm) species is
characterised by a slow ly lengthening,
serpiginous, intensely itchy rash.

Cutaneous Larval Migrans

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[ Q: 840 ] MRCPass - Haematology

Si -

# An 8 year old boy with sickle cell
disease presents with breathlessness. His Hb is
4.5 g/dl, WCC is 3 x 10 9 /L and platelet count is
35 x 10 9 /l_.

Which organism is likely to be responsible?

1- Coronavirus

2- HIV

3- HSV

Answer & Comments

Answer: 3- Chronic myeloid leukaemia

A high neutrophil count, platelet count points
towards myeloid leukaemia.

Acute leukaemia is defined as blast cells
comprising 30% (in this case only 10% of
myelocytes) of the cell type.

Hence it makes CML more likely than AML.

4- Parvovirus

5- Epstein barr virus

Answer & Comments

Answer: 4- Parvovirus

Parvovirus B19 is the commonest cause of
aplastic crisis in sickle cell anaemia. Recovery
should occur within 10 days with conservative
treatment.

[ Q: 841 ] MRCPass - Haematology

/ -

# A 45 year old man is being
investigated for easy bruising and malaise.
Investigations reveal:

Haemoglobin 9.5 g/dL

White cell count 90 x 10 9 /L

Neutrophils 45 x 10 9 /L (1.5-7)

Lymphocytes 3.5 x 10 9 /L (1.5-4)

Myelocytes 30 x 10 9 /L

Myeloblasts 3 x 10 9 /L

Platelet count 750 x 10 9 /L

Which of the following diagnosis is likely?

1- Acute myeloid leukaemia

2- Acute lymphocytic leukaemia

3- Chronic myeloid leukaemia

4- Chronic lymphocytic leukaemia

5- Polycythaemia rubra vera

[ Q: 842 ] MRCPass - Haematology

A 30 year old lady attends A&E with
severe nosebleeds. Her investigations show :

Hb 10.5 g/dl
MCV 80 fl
WCC 7 x 10 9 /L
platelets 3 x 10 9 /L

Blood film report: No platelet clumps seen.
Normal rbc and w be

Clotting screen normal

What is the most likely diagnosis?

1- Thrombotic thrombocytopenic purpura

2- Haemolytic uraemic syndrome

3- Acute lymphoblastic leukaemia

4- Disseminated intravascular coagulation

5- Immune thrombocytopenia

Answer & Comments

Answer: 5- Immune thrombocytopenia

As there is no abnormality in the red and
white blood cells on the blood film, this is
most likely to be immune thrombocytopenia.
Features consistent with a diagnosis of
immune thrombocytopenic purpura (ITP) are
thrombocytopenia with platelets being normal
in size or may appear larger than normal, but
uniformly giant platelets (approaching the size
of red cells) should be absent. The
morphology of red blood cells and white blood
cells should be normal.

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[ Q: 843 ] MRCPass - Haematology

A 72 year old lady has recently been
found to be anaemic. Further blood tests
show :

Hb of 9.2 g/dl

WCC of 8.0 x 10 9 /L

platelet count of 200 x 10 9 /L

MCV is 104 fl (80-96)

Ferritin is 120 pg/l (15-200)

red cell folate is 350 ?g/l (150-650)

B12 is 400 pmol/l (120-700)

Blood film shows anisocytosis and
poikilocytosis

Which of the following diagnosis is likely?

1- Chronic lymphocytic leukaemia

2- Autoimmune haemolytic anaemia

3- Sideroblastic anaemia

4- Iron deficiency

5- Lymphoma

Answer & Comments

Answer: 3- Sideroblastic anaemia

3- Serum IgE level

4- Venom toxin level

5- Complement C3 level

Answer & Comments

Answer: 3- Serum IgE level

Type I hypersensitivity is occurring in this case
of anaphylaxis. It takes 30 minutes from time
of exposure antigen. The reaction involves
production of IgE which is released from mast
cells.

[ Q: 845 ] MRCPass - Haematology

A 25 year old woman presents with
diffuse lymphadenopathy, fever and malaise.
Her blood film shows atypical lymphocytes
and red cell agglutination.

What is the most likely diagnosis?

1- Legionella

2- Infectious mononucleosis

3- Meningococcal meningitis

4- Non-Hodgkin's lymphoma

5- Autoimmune haemolytic anaemia

A high MCV with normal folate and B12 levels,
normal iron and a blood film showing
anisocytosis and poikilocytosis suggests
sideroblastic anaemia.

^ [ Q: 844 ] MRCPass - Haematology

/ -

# A 20 year old man presents with

acute severe dyspnoea. He had been stung by
a wasp several hours ago. On examination, he
was hypotensive and had signs of
bronchospasm.

Which one of the following investigations
would confirm the type of hypersensitivity
reaction?

1- Plasma tryptase level

2- ESR

Answer & Comments

Answer: 2- Infectious mononucleosis

Infectious mononucleosis is caused by Epstein
Barr virus. It is one of the common causes of
atypical lymphocytes, along with
cytomegalovirus, HIV and Toxoplasma. The
features of lymphadenopathy and atypical
lymphocytes suggest infectious

mononucleosis.

[ Q: 846 ] MRCPass - Haematology

A 62 year old man who was
asymptomatic, was referred for investigation
of a high white cell count routinely found by
the GP. On examination, he had palpable
splenomegaly and looked pale.

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Results reveal:

Haemoglobin 10.5 g/dl (11.5-16.5)

Platelet count 175 x 10 9 /L (150-400)

White cell count 32 x 10 9 /I (4-11)

Neutrophil count 4 x 10 9 /L (1.5-7)

Lymphocyte count 27 x 10 9 /L (1.5-4)

His Blood film shows many mature
lymphocytes

What is the best initial management?

1- Prednisolone

2- Period of observation

3- Radiotherapy

4- Splenectomy

5- Chlorambucil

Answer & Comments

Answer: 2- Period of observation

In chronic lymphocytic leukaemia, Indications
for therapy include fatigue, lymphadenopathy,
anaemia or thrombocytopenia.

All of the others are treatment options which
can be used.

[ Q: 847 ] MRCPass - Haematology

A 20 year old man presented with a
cough and fevers. He was diagnosed as having
a chest infection and was prescribed two
different antibiotics. He felt worse two days
later and mentioned that he had dark urine.

Investigations showed:

Hb 8.5 g/dl

MCV 75 fl

WCC 12 x 10 9 /L

platelets 155 x 10 9 /L

2- Autoimmune haemolytic anemia

3- Aplastic anemia

4- Immune thrombocytopenic purpura

5- Acute myeloid leukaemia

Answer & Comments

Answer: 1- G6PD deficiency

There is evidence of haemolysis (bite cells are
schistocytes), in this case most likely due to
G6PD deficiency. Drugs normally causing
haemolysis in G6PD deficiency are sulphur
containing-dapsone, anti-malarials,

bactrim/septrim, sulphonamides,

primaquinine.

[ Q: 848 ] MRCPass - Haematology

A 65 year old man has recently been
diagnosed as having a deep vein thrombosis.
He also has symptoms of headaches and
lethargy. On examination he was flushed.
Investigations reveal:

haemoglobin 19.5 g/dL

haematocrit 0.6 (0.4-0.52)

white cell count 10.5 x 10 9 /L (4-11)

platelet count 450 x 10 9 /L (150-400)

Which one of following is the most
appropriate investigation?

1- Serum EPO level

2- Bone marrowaspirate

3- Neutrophil alkaline phosphatase

4- Red cell mass

5- Serum Vitamin Bn levels

Answer & Comments

Answer: 4- Red cell mass

Blood film showed: anisopokilocytosis and
bite cells

What is the diagnosis?

1- G6PD deficiency

The most appropriate initial investigation will
be red cell mass studies which would will
distinguish between true relative
polycythaemia from secondary polycythaemia.

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In Polycythaemia Rubra Vera, the serum EPO
is low (an elevated EPO level suggests
secondary polycythaemia).

Haematocrit is high as is the Hb concentration.
Thrombocytosis and leukocytosis can occur.
The NAP score and B12 levels are frequently
increased.

[ Q: 849 ] MRCPass - Haematology

A 55 year old woman who had a
cerebrovascular accident ten month ago, was
referred for investigation of recurrent
episodes of proximal deep venous thrombosis
(DVT) of lower limbs in the last seven months.

Investigations show :

hemoglobin 7.9 g/dl

hematocrit 25%

mean corpuscular volume 99 fl

mean corpuscular hemoglobin 32 pg

white blood cells 4 x 10 9 .l

platelets 93 x 10 9 /L

reticulocytes 5.4%

lactate dehydrogenase 944 Ul/I

total bilirubin 50umol/l.

A bone marrow biopsy showed a slight
hyperplasia of erythrocytic bone marrow cell
line.

Urine Dipstick - blood +++

What is the likely diagnosis?

1- Haemolytic uraemic syndrome

2- Antithrombin III deficiency

3- Paroxysmal nocturnal haemoglobinuria

4- Protein C deficiency

5- Protein S deficiency

Answer & Comments

Answer: 3- Paroxysmal nocturnal

haemoglobinuria

Paroxysmal nocturnal haemoglobinuria (PNH)
is an aplastic anaemia like syndrome which
red cells are predisposed to complement lysis
and resultant haemolytic anaemia. There is a
pancytopenia as well as a tendency towards
Budd Chiari thrombosis.

The diagnostic test is the HAM test. Serum
(which contains complements) is acidified
(activates the complement pathway) and
mixed with red cells which undergo lysis.
Haemosiderin is a by product of haem
breakdown containing iron. Excess amounts
leads to renal damage, and is also lost in the
urine.

In PNH, there is a loss of anchor protein (GPI
glycosylphosphatidyl inositol) which hold
different antigens e.g. CD59, CD14. These are
regulatory proteins for the complement
pathway.

[ Q: 850 ] MRCPass - Haematology

A 17 year old patient has sickle cell
disease. He presents unwell with abdominal
pain. He also has right sided facial weakness.
Investigations:

Hb 7.5 g/dl
platelets 140 x 10 9 /L
Urea 8 mmol/l

creatinine 100 pmol/l
sodium 141 mmol/l

potassium 3.8 mmol/l
bilirubin 45 pmol/l

AST 35 U/l
ALP 105 U/l
Alb 42 g/l
LDH 1250 U/l

Blood film shows sickle cells

Which of the following is the most important
management?

1- Iv fluids

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2- Iv antibiotics

3- Diamorphine injections

4- Blood transfusion

5- Exchange transfusion

Answer & Comments

Answer: 5- Exchange transfusion

When there is neurological damage or visceral
sequestration crisis in sickle cell crisis,
exchange transfusion is indicated. Exchange
transfusion involves drawing out the patient's
blood while exchanging it for donor red blood
cells. It can be done manually or automatically
with erythrocytapheresis. It prevents stroke
and also may be used in patients with severe
acute chest syndrome and to reduce the risk
of iron overload in patients who require
chronic transfusion therapy. Studies suggest
that it may improve oxygenation and reduce
hemoglobin S levels.

[ Q: 851 ] MRCPass - Haematology

A 35 year old man presents with
pallor and breathlessness. Blood tests show
anaemia with a Hb of 7.5 g/dl. A blood film
shows Heinz bodies.

Which one of the following diagnoses is most
likely?

1- Autoimmune haemolytic anaemia

2- Sideroblastic anaemia

3- G6PD deficiency

4- Post splenectomy

5- Sickle cell disease

Answer & Comments

Answer: 3- G6PD deficiency

[ Q: 852 ] MRCPass - Haematology

Which one of these patient's results
is most likely to have a diagnosis of
chronic lymphatic leukaemia?

1- A white cell count of 35 x 10 9 /l_ and
immature lymphocytes with prominent
nucleoli in the peripheral blood

2- A white cell count of 15 x 10 9 /L and mature
lymphocytes with cleaved nuclei in the
peripheral blood film

3- A white cell count of 65 x 10 9 /l_ with
neutophils, myelocytes and promyelocytes
on the blood film

4- A white cell count of 25 x 10 9 /l_ and smear
cells on the peripheral blood film

5- A white cell count of 6 x 10 9 /l_, and mature
lymphocytes with polar villi on the blood
film

Answer & Comments

Answer: 4- A white cell count of 25 x 10 A 9/I
and smear cells on the peripheral blood film

Chronic lymphatic leukaemia is characterised
by a lymphocytosis. The blood film shows
mature lymphocytes with smear or smudge
cells (they are squashed cells).

[ Q: 853 ] MRCPass - Haematology

A 65 year old woman has a diagnosis
of chronic lymphocytic leukaemia (CLL).
During one follow up appointment she
mentions that she has got progressively more
lethargic.

Her investigations show :

Hb 7.5 g/dl, MCV 118 fl, platelets 180 x 10 9 /L,
lymphocytes 43 x 10 9 /L, reticulocyte count
10 %.

Heinz bodies are precipitated, denatured Hb
within red cells. They are present in G6PD
deficiency. (Fava beans cause haemolysis in
G6PD - 'Beans means Heinz' mnemonic).

Which test is most likely to give the correct
diagnosis?

1- Folate level

2- Marrow trephine

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3- Serum electrophoresis

4- Ferritin

5- Coomb's test

Answer & Comments

Answer: 5- Coomb's test

A raised reticulocyte count could have led to
the high MCV. The clinical picture is one of
haemolysis which is occasionally seen in CLL.
The Coomb's test will help to confirm this.

[ Q: 854 ] MRCPass - Haematology

A 28 year old man with glucose-6-
phosphate dehydrogenase deficiency presents
with fatigue and jaundice. The features
developed following a pneumonia a week ago.

Which of the following is likely to be found?

1- Low mean cell volume

2- Positive direct antiglobulin test

[ Q: 855 ] MRCPass - Haematology

A 60 year old Afro-Carribean man is referred
with abdominal discomfort. On examination,
he has massive splenomegaly. The FBC shows:

Hb 8.2 g/dl

WBC 15 x 10 9 /L

Platelets 110 x 10 9 /L

Blood smear: erythroblastic picture

Which of the following diagnoses is the most
likely?

1- Myelofibrosis

2- Polycythaemia rubra vera

3- Non-Hodgkin's lymphoma (NHL)

4- Aplastic anaemia

5- Chronic myeloid leukaemia

Answer & Comments

Answer: 1- Myelofibrosis

3- Spherocytes present on blood film

4- Haemoglobinuria

5- Reduced reticulocyte count

Answer & Comments

Answer: 4- Haemoglobinuria

The clinical scenario describes haemolytic
anaemia. Haemoglobinuria is seen in
haemolytic anaemia. Patient may present with
fatigue and tiredness. Low mean cell volume
would mean lack of reticulocytosis. This is
unlikely, there is usually increased reticulocyte
count in all haemolytic anaemias including
G6PD deficiency. Spherocytes are seen in
hereditary spherocytosis and the antiglobin
test is positive in autoimmune haemolytic
anaemia (not just G6PD deficiency).

Myelofibrosis existis likely to be the case
described above. Median age at diagnosis is
about 60 years, and median life expectancy
from onset of symptoms is 10 years. In
contrast, acute MF in adulthood is a rapidly
fatal disorder in which splenomegaly is not
usually observed; bone marrow examination
typically reveals numerous bizarre
megakaryocytes and blasts.

[ Q: 856 ] MRCPass - Haematology

A 32 year old woman presents to the
casualty with worsening dyspnoea over 3
weeks. She has no history of jaundice of
anaemia.

On examination, she had a blood pressure of
125/65 mmHg. Her conjunctivae were pale.
Abdominal examination was unremarkable
and there was no splenomegaly.
Investigations show :

Hb 6.5 g/dl

WBC 13.5 x 10 9 /L

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Pits 255 x 10 9 /L
MCV 105 fl
LDH 680 lU/dl

Direct Coomb's test positive

Film: Spherocytes ++, reticulocytes ++

What should be the treatment for her
condition?

1- Iron replacement

2- Bone marrow examination

3- Vitamin K

4- Immunosupressants

5- B12 and folate

Answer & Comments

Answer: 4- Immunosupressants

This woman is most likely to have
autoimmune haemolytic anaemia (anaemia,
high LDH, spherocytes on the blood film), and
positive Direct Coomb's test. Steroids,
intravenous immunoglobulin may be used as
first line treatment, and blood transfusion
may be necessary. Autoimmune haemolytic
anaemia can be due to immune disorders
(SLE), toxic chemicals and drugs, (methyldopa,
penicillin), antiviral agents (eg, ribavirin),
physical damage, and infections (infectious
mononucleosis).

^ [ Q: 857 ] MRCPass - Haematology

0 A 35 year old man presents with
fevers and lymphadenopathy. A bone marrow
biopsy was done and confirms Hodgkin's
lymphoma.

Which one of the following form has the best
prognosis?

1- Nodular sclerosing

2- Lymphocyte predominant

3- Lymphocyte depleted

4- Mixed cellularity

5- Promyelocytic

Answer & Comments

Answer: 2- Lymphocyte predominant

Hodgkin's lymphoma is rare in children.
Nodular sclerosing is the commonest and
lymphocyte depleted is the rarest form. The
lymphocyte predominant form has the best
prognosis, whilst the lymphocyte depleted
form has the worst.

[ Q: 858 ] MRCPass - Haematology

A 30 year old man presents with
malaise and is found to be anaemic clinically.
His blood tests reveal :

Hb of 10.5 g/dl

WCC 8 x 10 9 /L

platelet count 180 x 10 9 /dl

reticulcyte count 160 x 10 9 /L (50-100)

Bilirubin is 80 mmol/l

AST 30 U/l

ALP 110 U/l

LDH us 380 U/l (10-250)

Blood film shows spherocytosis

Which of the following tests is most
appropriate?

1- Direct antiglobulin test

2- G6PD activity

3- Hb electrophoresis

4- Urinary haemosiderin

5- Methaemoglobin levels

Answer & Comments

Answer: 1- Direct antiglobulin test

The blood tests with high bilirubin,
reticulocyte count and high LDH suggests
haemolysis. Spherocytes on blood film
suggests hereditary spherocytosis (HS). In HS
the red cells are smaller, rounder, and more
fragile than normal. The condition is
commoner among Northern Europeans. The

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direct antiglobulin test will help to confirm
this.

[ Q: 859 ] MRCPass - Haematology

A 40 year old man has presented
with seizures and has a confirmed cerebral
infarct on head scan. He is commenced on
phenytoin. 3 weeks later he presents with
lethargy.

His bloods show Hb 8.0 g/dl, MCV 95 fl, WCC
3.2 x 10 9 /l_, platelets 65 x 10 9 /l_, Reticulocyte
count 1%. Ham's test was negative. Bone
marrowaspirate and trephine biopsy showed
marked hypocellularity of the marrow with
some lymphoid aggregates.

Whot is the likely diagnosis?

1- Folate deficiency

2- Myelofibrosis

3- Aplastic anaemia

4- Multiple myeloma

5- Bony metastasis

Answer & Comments

Answer: 3- Aplastic anaemia

The diagnosis is likely to be phenytoin related
aplastic anaemia. MCV is normal and there is a
low reticulocyte count as well as hypocellular
bone marrow . Side effects of phenytoin are
cerebellar syndrome, phenytoin

encephalopathy, psychosis, locomotor
dysfunction, hyperkinesia, megaloblastic
anemia, decreased serum folate level,
decreased bone mineral content, liver disease,
IgA deficiency and gingival hyperplasia.

Haemoglobin 6.6 g/dL
MCV 108 fL
MCH 32.0 pg

White cell count 3.0 x 10 9 /L
Platelets 75xl0 9 /L
Serum Vitamin Bi 2 normal
Folate 2 (3-20) ?g/l
Whot should be done?

1- Treat congestive cardiac failure then
transfuse

2- Immediate blood transfusion

3- Serum electrophoresis

4- Iron replacement

5- B12 and folate replacement

Answer & Comments

Answer: 5- B12 and folate replacement

Blood transfusion may worsen cardiac failure
in this case. In patients who are folate
deficient erythropoiesis rapidly resolves when
supplements are given, and transfusion is
rarely needed in the elderly (unless the
anaemia is very severe).

[ Q: 861 ] MRCPass - Haematology

A 35 year old man has recently been
diagnosed with Hodgkin's lymphoma.

In reviewing his symptoms, which one of the
following indicates the poorest prognosis in
Hodgkin's lymphoma?

1- Mediastinal, inguinal lymphadenopathy and
fever

^ [ Q: 860 ] MRCPass - Haematology

/ -

# A 70 year old woman was admitted
to hospital with severe breathlessness. On
examination her blood pressure was 100/55
mmHg and she had a raised JVP by 4 cm.
Chest x ray showed mild pulmonary oedema.

Investigations revealed:

2- Mediastinal lymphadenopathy and night
sweats

3- Abdominal and inguinal lymphadenopathy,
and night sweats

4- Cervical and mediastinal lymphadenopathy

5- Mediastinal and inguinal lymphadenopathy.

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Answer & Comments

Answer: 1- Mediastinal, inguinal

lymphadenopathy and fever

Stage III disease occurs when lymph nodes are
present across both sides of diaphragm, hence
worse prognosis than when lymph nodes are
localised to the same side of the diaphragm.
Presence of B symptoms - night sweats and
fevers also worsen prognosis.

[ Q: 862 ] MRCPass - Haematology

A 25 year old man was admitted with
a 2 month history of rash, fatigue, intermittent
hemoptysis, and purpura, culminating in a
seizure. On examination, widespread
petechiae and purpura with scleral icterus
were noted.

There was no lymphadenopathy or
splenomegaly.

Answer & Comments

Answer: 3- Plasma exchange

Thrombotic thrombocytopenic purpura (TTP)
is characterised by microangiopathic
haemolysis and thrombocytopenia. There is a
spectrum of presentations with TTP-HUS.
Neurological features are present in 60% of
patients of TTP and renal failure is often
associated in HUS (haemolytic uraemic
syndrome).

[ Q: 863 ] MRCPass - Haematology
A 8 year old boy presents to his GP

with lethargy and pallor.

His investigations show :
Hb 5.5 g/dl
WBC 2.7 x 10 9 /L
Pits 42 x 10 9 /L

Investigations show :
platelet count 3 x 10 9 /L
hemoglobin 5.5 g/dL
mean corpuscular volume 90 fL
white cell count 19.6 x 10 9 /L

Neutrophils 0.9 x 10 9 /L

What is the next best investigation?

1- Peripheral blood immunophenotyping

2- Bone marrow cytogenetics

3- Haematinics

urea 16 mmol/L
creatinine 270 pmol/L
lactate dehydrogenase 2200 U/L
total bilirubin 79 pmol/L
haptoglobin 6 g/L

Blood film shows anisocytosis, moderate to
marked polychromasia, and slight to moderate
poikilocytosis, predominantly schistocytes.

What is the best treatment option?

1- Haemodialysis

2- Azathioprine

3- Plasma exchange

4- Bone marrow transplant

5- Intravenous immunoglobulins

4- Bone marrow aspirate and trephine

5- ANA and Rheumatoid factor

Answer & Comments

Answer: 4- Bone marrow aspirate and
trephine

Pancytopenia may be due to bone marrow
failure (aplastic anaemia) or to bone marrow
infiltration (leukaemia, lymphoma or non-
haemopoietic malignancy). Aplastic anaemia
may be idiopathic or secondary to drugs,
paroxysmal nocturnal haemoglobinuria or
Fanconi's anaemia. In a child of this age,
leukaemia (ALL, AML) or aplastic anaemia
would be the most likely causes of
pancytopenia.

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[ Q: 864 ] MRCPass - Haematology

A 38 year old woman presents to the
haematologist for reviewas she has

lethargy.

She is on iron tablets. Her blood results show:

Hb 9.5 g/dl
MCV 105 fl
WCC 7 x 10 9 /L
platelets 218 x 10 9 /L

Blood film shows anisopoikilocytosis and
poikilocytosis

What should be done next?

1- Intramuscular iron therapy

2- Blood transfusion

3- Erythropoietin

4- Investigation for folate eficiency

5- No immediate action

Answer & Comments

Answer: 5- No immediate action

The blood film and poor response to iron
therapy suggests sideroblastic anaemia.

Sideroblastic anaemia is managed by
removing the precipitating factors e.g. alcohol
or myelodysplasia.

5- Hepatitis C infection

Answer & Comments

Answer: 2- Haemolysis due to G6PD deficiency

G6PD deficiency is common in the
Mediterranean and African populations.
Inheritance is X-linked. Intravascular
haemolysis is usually precipitated by oxidative
stress, such as infections and drugs. The most
common drugs implicated are anti-malarials,
dapsone and sulphonamides.

[ Q: 866 ] MRCPass - Haematology

A 20 year old man complains of
intermittent dark urine and abdominal pains.
He is found to have a haemoglobin of 9.7 g/dl,
but the rest of the full blood count is normal.

What is the most likely diagnosis?

1- Autoimmune haemolytic anaemia

2- G6PD deficiency

3- Paroxysmal nocturnal haemoglobinuria

4- Paroxysmal cold hemoglobinuria

5- Hereditary spherocytosis

Answer & Comments

Answer: 3- Paroxysmal nocturnal

haemoglobinuria

[ Q: 865 ] MRCPass - Haematology

A 23 year old man presents with
jaundice during a planned holiday to Africa.
He has been taking malarial prophylaxis.

He is apyrexial and apart from lethargy, feels
well. He reports passing dark urine for the
past two days.

What is the likely cause?

1- Beta thalassemia

2- Haemolysis due to G6PD deficiency

3- Sickle cell crisis

4- Falciparum malaria

Paroxysmal nocturnal haemoglobinuria is
caused by a defect in the formation of a red
cell surface protein anchor, called GP1. As a
result of the lack of this surface protein
anchor, the red blood cells are more sensitive
to complement lysis. Patients have
intravascular haemolysis, leading to
haemoglobinuria, and increased risk of
thrombosis, often occurring in the mesenteric
vessels and the portal vein. Treatment is
supportive or with bone marrow
transplantation.

[ Q: 867 ] MRCPass - Haematology

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A 35 year old man has had a 4 day history of
dark urine. He has recently been on an
antibiotic for a presumed urinary tract
infection.

His blood tests show:

Hb 5.0 g/dl MCV 103 fl

MCHC 34 g/dl (32-35) WCC 8 x 10 9 /L
reticulocytes 160 x 10 9 /L (50-100)
platelets 130 x 10 9 /L

PT 13s (11.5-15.5) APTT 38 s (30-40)

urea 6 mmol/l creatinine 90 mmol/I

sodium 140 mmol/l potassium 4 mmol/l

bilirubin 48 (1-22) mmol/l

AST 18 (1-31) U/l ALP 150 (20-120) U/l

albumin 32 g/l

LDH 1550 U/l (10-250)

Blood film shows blister cells.

Whot is the diagnosis?

1- Autoimmune haemolytic anaemia

2- Hereditary spherocytosis

3- Paroxysmal nocturnal haemoglobinuria

4- G6PD deficiency

5- Porphyria

Answer & Comments

Answer: 4- G6PD deficiency

The patient's clinical and laboratory findings
(eg, markedly decreased hemoglobin and
hematocrit levels with a markedly increased
serum LDH activity), are characteristic of acute
oxidant damage to the red blood cells and
hemolysis due to glucose-6-phosphate
dehydrogenase (G6PD) deficiency.

The blood film in G6PD deficiency shows
blister cells (membrane protrusion) (Heinz
bodies may also be seen when there is no
haemolysis). Treatment is with blood
transfusion, or in severe cases, exchange
transfusion.

Hemolytic crisis occurs only after exposure to
certain offending agents, including drugs,
infections, exposure to fava beans, and
diabetic acidosis. Drugs associated with
hemolysis in G6PD deficiency include
antimalarials (Primaquine, pamaquine),
sulphonamides (Sulphamethoxazole),

nitrofurantoin, analgesics (acetaminophen,
aspirin, phenacetin), isoniazid (I NH),
methylene blue, and nalidixic acid.

[ Q: 868 ] MRCPass - Haematology

A 32 year old Cypriot patient is being
investigated for anaemia. He has a Hb of 7.5
g/dl and MCV is 70 fl. His brother and sisters
are also anaemic.

Which one of the following is most likely?

1- Increased IgM band on serum
electrophoresis

2- Red cells show marked hypochromia

3- Severe iron deficiency due to Gl bleeding

4- Severe B12 deficiency due to pernicious
anaemia

5- Severe folate deficiency due to celiac
disease

Answer & Comments

Answer: 2- Red cells show marked
hypochromia

This patient is likely to have thalassaemia
(probably major). Hb electrophoresis may
show increased HbA2 in thalassaemia minor.
The severe imbalance of globin chain synthesis
(alpha » beta) results in ineffective
erythropoiesis and severe microcytic
hypochromic anemia, there may also be
precipitates within damaged red cells.

[ Q: 869 ] MRCPass - Haematology

A 35 year old man has known type 1
Von Willebrand's disease.

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Prior to surgery , which is the best test to
assess bleeding tendency?

1- Prothrombin time

However, after adolescence, the disease tends
to run a chronic relapsing course and
therefore requires therapy.

2- Factor VIII antigen

3- Factor VIII levels

4- Bleeding time

5- Thrombin time

Answer & Comments

Answer: 2- Factor VIII antigen

Bleeding time is usually prolonged, and does
not provide quantification of bleeding
tendency. Factor VIII antigen measures the
presence of vWF and gives a good estimate of
tendency to bleed.

^ [ Q: 870 ] MRCPass - Haematology

m An 19 year old man presents to the
A&E with a petechial rash and platelet count
of 5 x 10 9 /l_. He is otherwise well. A diagnosis
of idiopathic thrombocytopenic purpura is
made.

Which of the following statements is true?

First line therapy is oral steroids. Patients who
are refractory to, or are intolerant of steroids
may respond to intravenous immunoglobulins
(IVIg) or anti-D.

[ Q: 871 ] MRCPass - Haematology

A 35 year old man has a faint
maculopapular rash on his chest and a few
shotty lymph nodes. His bloods show Hb 13.5
g/dl, WCC 14.0 x 10 9 /L, pits 300 x 10 9 /L. Blood
film shows reactive lymphocytes.

Which of the following diagnosis is likely?

1- Tuberculosis

2- Non hodgkin's lymphoma

3- Hepatitis B

4- Infectious mononucleosis

5- Pneumonia

Answer & Comments

Answer: 4- Infectious mononucleosis

1- The patient should be given a platelet
transfusion

2- The patient should be observed

3- The patient should be treated with Anti-D

4- The patient should be treated with
intravenous immunoglobulin

5- The patient should be commenced on
steroids

Answer & Comments

Answer: 5- The patient should be commenced
on steroids

There are several reactive lymph nodes as well
as reactive lymphocytes suggestive of Ebstein
Barr virus infection / infectious
mononucleosis. Other causes of reactive
lymphocytes are CMV infection, toxoplasmosis
and HIV.

[ Q: 872 ] MRCPass - Haematology

A 65 year old woman has symptoms
of easy bruising. She was referred by the GP
for investigation. On examination, she had
splenomegaly.

Results show :

In younger patients with ITP, the disease
usually remits spontaneously within several
weeks and no treatment is usually required
unless there is significant bleeding.

Haemoglobin 6.5 g/dL (11.5-16.5)
White cell count 17 x 10 9 /I (4-11)
Platelet count 32 x 10 9 /I (150-400)

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Blood film shows lymphocytosis, myeloblasts
and promyelocytes.

Which one of following investigations is of
prognostic value in this situation?

1- Blood film

2- Bone marrowaspirate

3- Cytogenetic karyotyping

4- Immunophenotyping

5- Serum electrophoresis

Answer & Comments

Answer: 3- Cytogenetic karyotyping

Cytogenetic monitoring of the clinical course
of acute myeloid leukaemia (suggested by
blasts) is often associated with a specific
chromosomal change, ie, t(8;21) in M2.
Establishment of the change at diagnosis
allows recognition of the leukemic cells in the
marrow when relapse or residual disease is to
be evaluated. It also provides a prognostic
determinant.

[ Q: 873 ] MRCPass - Haematology

A 52 year old female presents with
acute chest pain and breathlessness. The
chest pains were pleuritic and started to
develop a week ago. Examination reveals
prominent P2 and clear breath sounds. She
had bilateral ankle oedema. A urine dipstick
showed protein +++.

AT III deficiency is associated with venous
thrombosis. In this case, the history is
consistent with a clinical diagnosis of
pulmonary emboli and renal vein thrombosis.

^ [ Q: 874 ] MRCPass - Haematology

/% -

# A 35 year old man has had allogeneic

bone marrow transplantation which is HLA
matched. 2 weeks later he develops a diffuse
rash all over his body, feels sick and vomits
several times. His temperature is 38°C. Blood
tests show :

Hb 11.0 g/dl

WCC 3 x 10 9 /L

Neutrophils 1.5 x 10 9 /L

platelets 18 x 10 9 /L

PT 18s (11.5-15.5)

urea 7 pmol/l

creatinine 70 pmol/l

sodium 135 mmol/I

potassium 4 mmol/l

bilirubin 28 pmol/l

AST 48 U/l

ALP 155 U/l

albumin 32 g/l

LDH 550 U/l

Which of the following is most likely?

1- Bone marrow failure

Which is the most likely explanation for these
findings?

1- Factor V Leiden

2- Reduced antithrombin III activity

3- Reduced levels of Von Willebrand's factor

4- Reduced d dimer concentration

5- Reduced factor VIII

2- Parvovirus infection

3- Leukaemic spread

4- Aplastic anaemia

5- Graft versus host disease

Answer & Comments

Answer: 5- Graft versus host disease

Answer & Comments

Answer: 2- Reduced antithrombin III activity

The rash, systemic symptoms, deranged liver
enzymes point towards GVHD. T cells from the
donor are attacking the recipient. Treatment

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is with immunosuppression: ciclosporin,
methylprednisolone, methotrexate or
antithymocyte globulin (ATG).

month history of lower back pain and
weakness.

His blood tests show :

[ Q: 875 ] MRCPass - Haematology

A 25 year old woman presented
unwell with diarrhoea occurring 5 times a day
for 4 days. She had not passed urine for a day.

Investigations:

Haemoglobin 8.2 g/dL

White cell count 14.2 x 10 9 /L

Neutrophils 10.5 x 10 9 /L

Platelets 32 x 10/L

Fibrinogen 5 g/dL

Serum sodium 138 mmol/L

Serum potassium 6.3 mmol/L

Serum urea 38 mmol/L

Serum creatinine 450 umol/L

Serum albumin 29 g/L

Dipstick urine Blood + Protein +

What is the diagnosis?

1- Idiopathic thrombocytopenic purpura

2- Myelodysplastic syndrome

3- Disseminated intravascular coagulation

4- Haemolytic uraemic syndrome

5- Aplastic anaemia

Answer & Comments

Answer: 4- Haemolytic uraemic syndrome

The most likely diagnosis is Haemolytic
uraemic syndrome due to diarrhoea
associated with E coli infection. A stool sample
for culture and blood film are important
investigations to be performed.

[ Q: 876 ] MRCPass - Haematology
A 60 year old man has a several

Hb 11.0 g/dl
MCV 95 fl
WCC 2.5 x 10 9 /L
platelets 130 x 10 9 /L
PT 13 s (11.5-15.5)

APTT 28s (30-40)

urea 26 pmol/l

creatinine 280 pmol/l

sodium 138 mmol/l

potassium 4 mmol/l

bilirubin 38 pmol/l

AST 26 U/l

ALP 150 U/l

albumin 33 g/l

total protein 95 g/l

What is the most likely diagnosis?

1- Multiple myeloma

2- Metastatic bladder carcinoma

3- Lymphoma

4- Paraglanglioma

5- Chronic myeloid leukaemia

Answer & Comments

Answer: 1- Multiple myeloma

Multiple myeloma is most likely. There is
raised protein (60-80 normal range) indicated
probably paraproteinaemia. There is also low
white cell count due to bone marrow
infiltration, and renal failure. The symptoms of
bone pain also suggests infiltration.

[ Q: 877 ] MRCPass - Haematology
A 20 year old girl is being

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investigated for anaemia. Her father has
previously had a splenectomy. Her blood film
shows spherocytes and anaemia.

In view of the likely diagnosis , which is the
most useful investigation?

1- Reticulocyte count

2- Mott cell

3- Haemosidnerinuria

4- Haptoglobin

5- IgG and C3 complement

Answer & Comments

Answer: 5- IgG and C3 complement

This patient is likely to have hereditary
spherocytosis in view of the family history and
that the father has had splenectomy as
treatment. How ever, raised reticulocyte
count and decreased haptoglobins and
increased haemosidurinuria will be all be
present as a single test, unhelpful. The Direct
Antiglobulin Test is used to detect IgG or C3
bound to the surface of the red cell. In this
scenario, it is helpful to exclude autoimmune
haemolytic anaemia, since spherocytes would
also be present on the blood film in AIHA.

[ Q: 878 ] MRCPass - Haematology

A 34 year old lady has a past history
of an episode of deep vein thombosis and two
miscarriages. She presents now with further
episoder of DVT. She had a thrombophilia
screen and was found to have a positive anti
cardiolipin antibody.

What is the best treatment?

1- Clopidogrel

2- Warfarin 3 months

3- Long term low molecular weight heparin

4- Aspirin and Warfarin

5- Lifelong warfarin

Answer & Comments

Answer: 5- Lifelong warfarin

This patient with recurrent DVTs has the
presence of lupus anticoagulant. She requires
lifelong warfarin treatment.

[ Q: 879 ] MRCPass - Haematology

A 40 year old male who has a
rheumatoid arthritis is admitted with a urinary
tract infection.

Results show :

haemoglobin 7.5 g/dL (11-16)

white cell count 1.5 x 10 9 /L (4-11)

platelets 70 x 10 9 /L (150-400)

Which one of the following drugs is the most
likely cause of pancytopenia?

1- Azathioprine

2- Cyclophosphamide

3- Prednisolone

4- Cyclosporin

5- Chloroquine

Answer & Comments

Answer: 1- Azathioprine

Azathioprine is a thiopurine analogue drug
which is metabolised in the liver to
mercaptopurine. The main side effects are
bone marrow suppression (may lead to a
pancytopenia) and also drug induced
hepatitis.

[ Q: 880 ] MRCPass - Haematology

A 50 year old man presents with
multiple bruises in the arms after working in
the garden.

Investigations showed: Hb 13.2 g/dl, WCC 5 x
10 9 /L, platelet count 5 x 10 9 /L.

A bone marrow examination showed normal
numbers of megakaryocytes and a diagnosis

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of idiopathic thrombocytopenic purpura was
made.

Whot is the most appropriate treatment?

1- Tranexemic acid

2- Oral prednisolone

3- Blood transfusion

4- Platelet transfusions

5- Intravenous immunoglobulin

Answer & Comments

Answer: 2- Oral prednisolone

The most appropriate treatment for this
patient who is symptomatic from ITP is oral
prednisolone. If the bleeding becomes severe,
then IV immunoglobulin should be considered
in addition to the steroids.

[ Q: 881 ] MRCPass - Haematology
An 12 year old girl has recurrent

epistaxis.

Her investigations show:

Hb 11 g/dl, Pits 300 x 10 9 /L, PT 16 sec (13-16
sec), aPTT 95 sec (28-38 sec).

Which of the following deficiencies is most
likely?

1- Factor V deficiency

2- Factor VII deficiency

3- Von Willebrand's factor

4- Anticardiolipin antibody

5- Factor X deficiency

Answer & Comments

Answer: 3- Von Willebrand's factor

von Willebrand's disease would be most likely
due to the prolonged APTT, the rest of the
factors (same ones as those which warfarin
act on) prolong PT.

[ Q: 882 ] MRCPass - Haematology

A 70 year old man is on lifelong oral
anticoagulation for recurrent DVT.

He presents with minor bleeding from his
gums for 1 day.

His INR is 9.0.

All other investigations are normal and he is
otherwise well.

What is the most appropriate course of
action ?

1- Stop warfarin, monitor INR and restart
when INR <5.0

2- Stop warfarin and administer Vitamin K 2
mg

3- Stop warfarin and institute either LMW
heparin

4- Stop warfarin and give FFP

5- Reduce dose of warfarin to 0.5 mg until INR
normalises

Answer & Comments

Answer: 1- Stop warfarin, monitor INR and
restart when INR <5.0

If there is only minor bleeding, then cessation
of warfarin is all that is required. If there are
other risk factors or if there is major bleeding
then the use of vitamin K or fresh frozen
plasma should be considered.

[ Q: 883 ] MRCPass - Haematology

A 65 year old lady has a diagnosis of
Non Hodgkin's lymphoma and has recently
commenced chemotherapy. She now
complains of feeling breathless and unwell.

On examination, she is pale and slightly
jaundiced. She has splenomegaly.

Investigations show :

Hb 3.5 g/dl

MCV 106 fl

WCC 8 x 10 9 /L

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platelets 250 x 10 9 /L
Reticulocytes 125 x 10 9 /L (N 20-90)

Her FBC pre-chemotherapy was normal.
Whot is the most likely explanation for this?

1- Paroxysmal cold haemoglobinuria

2- Bone marrow suppression

3- Megaloblastic anaemia

4- Autoimmune haemolysis

5- Paroxysmal nocturnal haemoglobinuria

Answer & Comments

Answer: 4- Autoimmune haemolysis

[ Q: 885 ] MRCPass - Haematology

A 13 year old child has had recurrent
episodes of bone pain. He has been admitted
to hospital several times due to severe pains
in the last 5 years.

He has X rays which show necrosis of the hip.
Which of the following diagnosis is likely?

1- Multiple myeloma

2- Paget's disease

3- Osteopetrosis

4- Sickle cell disease

5- Thalassemia

Anaemia, raised MCV and high reticulocyte
count suggests haemolysis. This may occur
secondary to NHL. In addition, there is a
strong association with fludarabine.

[ Q: 884 ] MRCPass - Haematology

A patient has had a splenectomy
because of hereditary spherocytosis.

How long should penicillin prophylaxis be
used?

1- During acute infections

2- 1 year

3- 10 years

4- 15 years

5- Life long

Answer & Comments

Answer: 5- Life long

Answer & Comments

Answer: 4- Sickle cell disease

Aseptic necrosis of the hip, cholecystitis, renal
papillary necrosis and proliferative
retinopathy are clinical features of sickle cell
disease.

[ Q: 886 ] MRCPass - Haematology

A 20 year old woman with sickle cell
anemia presents with acute shortness of
breath. A chest x ray obtained with a portable
unit initially showed no abnormalities except
for bibasilar hazy opacities.

Five and a half hours after admission, her
oxygen saturation decreased to 76 percent
with a respiratory rate of 24 breaths per
minute. A repeat chest radiograph revealed
increased interstitial markings.

How should she be treated?

Following splenectomy, patients should
receive lifelong penicillin prophylaxis. The
major complication of splenectomy is overw
helming sepsis with encapsulated bacteria (eg,
S pneumoniae, H influenzae, N meningitidis).
The overall risk of sepsis in asplenic patients is
approximately 2% but varies depending on the
age and underlying diseases.

1- Antibiotics and fluids

2- Intubation and ventilation

3- Noninvasive ventilation and plasma
exchange

4- Splenectomy

5- High flow oxygen

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Answer & Comments

Answer: 3- Noninvasive ventilation and plasma
exchange

Haemolytic disease of the new born was
suspected.

Which of these statements is likely?

This is a case of acute chest syndrome related
to sickle cell anaemia. Non invasivve
ventilation (CPAP) and plasma exchange is the
best option, often along with antibiotics
because the chest syndrome can be
precipitated by infection.

[ Q: 887 ] MRCPass - Haematology

A 25 year old female has had her
first DVT when she started taking the oral
contraceptive pill.

She reveals that her mother has also had DVT
before.

Which of the following is she likely to hove?

1- Factor V leiden deficiency

2- Protein C deficiency

3- Protein S deficiency

4- Antithrombin III deficiency

1- Father is 0 Rh -ve

2- Father is AB Rh +ve

3- Mother is AB Rh +ve

4- Father is AB Rh -ve

5- Mother is 0 Rh +ve

Answer & Comments

Answer: 2- Father is AB Rh +ve

To Answer this question, ABO group is less
relevant and Rh status is relevant.

Rh grouping of foetus is decided by the Rh
status of the father. The first child would have
been Rh +ve and led to sensitisation
(antibodies developed by the mother). The
mother is Rh -ve and the father is Rh +ve (who
could also be homozygous or heterozygous for
Rh).

5- Lupus anticoagulant

Answer & Comments

Answer: 1- Factor V leiden deficiency

Although they are all possibilities, the family
history suggests factor V leiden or
antithrombin III deficiency. A female who has
DVT precipitated by the OCP suggests factor V
leiden more so than antithrombin III (male
would suggest this).

[ Q: 889 ] MRCPass - Haematology

A 35 year old man complains of leg
cramps and is given quinine for the first time
by his GP. He then presents unwell and
complains of dark urine, his Hb is 7.4 g/dl.
Direct antiglobulin test (DAT) test is negative.

Which of the following is likely?

1- G6PD deficiency

2- Autoimmune haemolytic anaemia

3- Paroxysmal cold haemoglobinuria

[ Q: 888 ] MRCPass - Haematology

A 32 year old lady had a new born
baby with marked jaundice.

Serum bilirubin was 359 mmol/L and
haemoglobin low .

4- Phosphokinase deficiency

5- Sickle cell disease

Answer & Comments

Answer: 1- G6PD deficiency

The mother has had one previous normal
delivery.

The direct antiglobulin test (Coomb's) is
negative and suggests that this is not
autoimmune since there is no antibody

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opsonisation on red cells. Quinine can
precipitate haemolysis in G6PD deficiency as
can aspirin, sulphonamides, fava beans and
antimalarial agents.

[ Q: 890 ] MRCPass - Haematology

A 40 year old lady with presents with
chronic discomfort in left upper quadrant of
the abdomen. Investigations show :

Hb 16.9 g/dl
MCh 55 (28-32) pg
MCV 69 fl

White cell count 11 x 10 9 /L

Platelets 490 x 10 9 /L

Whot is the underlying couse ?

Laboratory investigations revealed
hemoglobin of 4.5 gm/dL, and platelet count
342 x 10 9 /L.

Peripheral smear showed anisocytosis(+),
poikilocytosis(+), spherocytosis(-), heinz body
(+), sickling(-) and reticulocyte count 6.2%.

Other results: aspartate aminotransferase 420
iu/L, alanine aminotransferase 104 iu/L,
indirect bilirubin 5.2 mg/dL, lactate
dehydrogenase 721 iu/L. Direct Coombs test
was negative.

Urine analysis: red colored, protein (+),
billirubin (+++).

Whot is the most likely diagnosis?

1- Haemolytic uraemic syndrome

2- Sickle cell disease

1- Essential thrombocythaemia

2- Primary polycythaemia

3- Renal cell carcinoma

4- Myelodysplasia

5- Chronic myeloid leukaemia

Answer & Comments

Answer: 2- Primary polycythaemia

The raised Hb, white cell and platelet count
are consistent with polycythaemia rubra vera.
Splenomegaly is common, and occasionally
splenic infarction as well which may lead to
left upper quadrant pains. Essential
thrombocythaemia is associated with
anaemia.

[ Q: 891 ] MRCPass - Haematology

A 30 year old man presents with
reddish urine and paleness. He mentions
recently travelling to Asia and being on
malarial prophylaxis. On physical examination
he had an axillary temperature of 36.5oC,
pulse of 120/min, respiratory rate of 28/min
and blood pressure of 80/60 mmHg. Other
physical findings were normal.

3- Malaria

4- G6PD deficiency

5- Hereditary spherocytosis

Answer & Comments

Answer: 4- G6PD deficiency

Patients with G6PD deficiency are often
asymptomatic. Chronic haemolysis does not
occur, but haemolysis rather is precipitated by
drugs such as chloroquine, primaquine,
vitamin K, sulphonamides. G6PDH catalyzes
the synthesis of NADPH from the hexose
monophosphate pathway. Deficiency leads to
oxidative damange and red cell haemolysis.

)

°oo <

o'- O'

eO A • C

oo -O

oo 0o

° O /* o.

Acute hemolysis in G6PD deficiency, with two

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^ [ Q: 892 ] MRCPass - Haematology

ft -

# An 12 year old boy bleeds
excessively after a laceration. Investigations
show:

Hb 13.5 g/dl
WBC 5.8 x 10 9 /l_

Pits 270 x 10 9 /L
PT 15 sec (13-16 sec)

APTT 85 sec (28-38 sec)

Factor VIII and Factor IX levels : normal

APTT 50:50 mix with normal plasma : 37 sec

Which of the following is the most likely
diagnosis?

1- Haemophilia A

2- Factor XI deficiency

3- Factor X deficiency

4- Factor XII deficiency

5- Factor VII deficiency

Blood cultures did not grow any organisms.
Despite intravenous antibiotics, the patient
remained pyrexial.

What is the likely cause?

1- CMV

2- Candidiasis

3- Metastatic disease

4- Tuberculosis

5- Rubella

Answer & Comments

Answer: 1- CMV

The likely cause of persisting pyrexia plus
hepatitis in this immunocompromised patient
after treated with appropriate antibiotics
would be a CMV infection. CMV infection can
also cause a pneumonitis and colitis.
Treatment with an antiviral agent such as
ganciclovir could be considered.

Answer & Comments

Answer: 2- Factor XI deficiency

An isolated prolonged APTT will be caused by
deficiencies in factors VIII, IX, XI and XII and by
von Willebrand's disease. Factor XII deficiency
is not associated with increased bleeding.

With normal Factor VIII and IX levels, this
patient is most likely to have Factor XI
deficiency. Factor XI deficiency is a mild
bleeding disorder with autosomal co¬
dominant inheritance. Diagnosis is by specific
Factor XI level estimation.

[ Q: 893 ] MRCPass - Haematology

A 48 year old man has a diagnosis of
acute myeloid leukaemia. He was given
chemotherapy. A few weeks into induction
chemotherapy, he develops jaundice and
fevers.

[ Q: 894 ] MRCPass - Haematology

A 60 year old woman presents with
cervical lymphadenopathy and

hepatosplenomegaly. Investigations reveal:

Hb 10.5 g/dl

WBC 4.6 x 10 9 /L

Plats 125 x 10 9 /L

serum electrophoresis : IgM paraprotein
detected, IgA and IgG levels are normal

The most likely diagnosis is:

1- Monoclonal gammopathy of uncertain
significance (MGUS)

2- Chronic lymphocytic leukaemia

3- Hodgkin's lymphoma

4- Waldenstrom's macroglobulinaemia

5- Multiple myeloma

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Answer & Comments

Answer: 4- Waldenstrom's

macroglobulinaemia

The fact that there is IgM paraprotein
suggests Waldenstrom's macroglobulinaemia.
Waldenstrom's macroglobulinemia is a
lymphoplasmacytic lymphoma (invasion of
bone marrow ) that leads to secretion of IgM.
Increased blood viscosity may result in
thrombotic phenomenon, weakness,
cryoglobulinemia, neurologic disorders, and
fatigue.

Multiple plasmacytoid cells in Waldenstrom's

macroglobulinaemia

[ Q: 895 ] MRCPass - Haematology

history of night sweats. On
examination, he had lymphadenopathy
palpable in the cervical region and
hepatosplenomegaly.

Investigations:

hemoglobin 8 g/dL

leukocyte count of 6.6 x 10 9 /L

A lymph node biopsy of right neck was
performed. It showed effaced normal
architecture and clusters and sheets of Reed-
Sternberg cells

What is the most likely diagnosis?

1- Essential thrombocythaemia

2- Acute myeloid leukaemia

3- Chronic myeloid leukaemia

4- Hodgkin's disease

5- Infectious mononucleosis

Answer & Comments

Answer: 4- Hodgkin's disease

Common presenting features for Hodgkin's
diseaese are Pel Ebstein fever, weight loss,
alcohol induced pain and lymphadenopathy.
Cold agglutinins can occur, leading to possible
haemolytic anaemia.

Reed-Sternberg cell in Hodgkin's disease with
large, prominent nucleoli.

[ Q: 896 ] MRCPass - Haematology

A 45 year old woman has a history of
recurrent anaemia was noted have target cells
and Howell Jolly bodies on a blood film
examination. Investigations show :

Haemoglobin 7.8 g/dL

MCV 75 fl MCH 27 pg (28-32)

Serum B12 132 ug/L (160-760)

Red cell folate 90 ug/L (160-640)

Serum ferritin 9 ug/L (15-300)

Which antibody is likely to be present?

1- Anti mitochondrial antibody

2- Intrinsic factor antibody

3- Anti endomysial antibody

4- Anti thyroid antibody

5- Anti gastric parietal cell antibody

Answer & Comments

Answer: 3- Anti endomysial antibody

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This patient has iron, folate and B12
deficiency. This is most likely due to coeliac
disease.

FBC shows anaemia in 50% of coeliac disease
patients; iron and folate deficiency are both
common (microcytes and macrocytes),
hypersegmented leucocytes and Howell-Jolly
bodies (hyposplenism).

The preferred investigations are IgA Anti¬
tissue transglutaminase (tTG) or IgA
Endomysial (EMA) antibodies. Antigliadin
antibodies are less specific, they can be
positive in Crohn's as well.

Howell-Jolly bodies are spherical blue-black
inclusions within red blood cells (iron
deficiency, thalassemia, post splenectomy)

[ Q: 897 ] MRCPass - Haematology

A 35 year old woman presents with
jaundice and lethargy. Investigations reveal:

Haemoglobin 8.5 g/dL (11-16)

White cells 7 x 10 9 /L

Platelets 190 x 10 9 /L

reticulocyte count 130 x 10 9 /L (25-85)

serum bilirubin 55 umol/L (1-20)

Blood film shows spherocytes

Which of the following should be done?

1- Direct antiglobulin test

2- Ultrasound of the abdomen

3- Bone marrow biopsy

4- Bone marrow aspirate

5- G6PD enzyme level

Answer & Comments

Answer: 1- Direct antiglobulin test

One of the first tests to consider in a patient
with haemolytic anaemia is the direct
antiglobulin test (Coomb's). This to exclude
autoimmune haemolytic anaemia.

[ Q: 898 ] MRCPass - Haematology

A 42 year old woman has a history of
positive lupus anticoagulant. She had a
pulmonary embolus diagnosed 8 years ago,
and two presentations which were consistent
with deep vein thrombosis 6 and 12 months
go.

Whot is the best management?

1- High dose aspirin

2- Lifelong warfarin

3- Antenatal advice

4- Avoidance of oral contraceptive pill

5- 6 months of warfarin then reassess

Answer & Comments

Answer: 2- Lifelong warfarin

More than one thrombotic event with the
presence of lupus anticoagulant suggests that
the patient requires lifelong warfarin.

[ Q: 899 ] MRCPass - Haematology

A 65 year old woman has a
haemoglobin of 5.5 g/dl. She has lethargy but
no other symptoms.

Her blood film shows oval macrocytes and
hypersegmented neutrophils. She has a
history of hypothyroidism and is on thyroid
replacement. She also has vitiligo.

What is the most likely diagnosis?

1- Multiple myeloma

2- Myelodysplasia

3- Pernicious anaemia

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4- Iron deficiency anaemia

5- Haemolytic anaemia

adrenal vein thrombosis and can cause
hypoadrenalism as in this case.

Answer & Comments

Answer: 3- Pernicious anaemia

Pernicious anaemia (PA) is a disease of the
stomach that is characterised by megaloblastic
anaemia due to vitamin Bn deficiency. It is
secondary to intrinsic factor deficiency and
gastric atrophy. It usually has an autoimmune
basis. Pernicious Anaemia primarily affects the
elderly - most patients are over 60 years of
age. Women are affected more often than
men, in a ratio of 3:2. It may be associated
with autoimmune diseases, such as Addison's
disease, hypothyroidism and also an increased
risk of gastric carcinoma.

[ Q: 900 ] MRCPass - Haematology

A 40 year old lady has been on
warfarin for previous DVT. She is now
breathless and a CTPA confirms pulmonary
embolus despite her INRs being in therapeutic
range of 2-3. She is also hyponatraemic with a
sodium of 129 mmol/l.

With the short synacthen test, she has a low
cortisol of 80nmol at 0 min going up to 200
nmol at 30 min.

Which of the following diagnosis is likely?

1- Autoimmune polyendocrine syndrome

2- Adrenal tumour

3- Protein C deficiency

4- Factor V leiden deficiency

5- Presence of lupus anticoagulant

Answer & Comments

Answer: 5- Presence of lupus anticoagulant

[ Q: 901 ] MRCPass - Haematology

A 20 year old girl receives a blood
transfusion. 5 minutes after the transfusion is
commenced, she develops a tachycardia and
abdominal pains.

Which of the following is the correct
management of an acute haemolytic
transfusion reaction due to ABO blood group
incompatibility?

1- Stop transfusion and assess

2- Repeat cross match and re-transfuse

3- Intravenous dextrose

4- Hydrocortisone lOOmg intravenously

5- Continue transfusion slowly

Answer & Comments

Answer: 1- Stop transfusion and assess

The immediate treatment of an acute
haemolytic transfusion reaction due to a
major blood group incompatibility is to
discontinue the blood transfusion
immediately. This should be followed by
assessment for possible shock and
resuscitation with fluids e.g. colloids.

[ Q: 902 ] MRCPass - Haematology

A 35 year old man has recently been
commenced on low molecular weight heparin
and then warfarin following a diagnosis of
DVT.

Which of the following is well known long term
side effect of heparin?

1- Polycythaemia

2- Visual loss

Antiphospholipid syndrome is most likely due
to the recurrent thrombotic tendency, lupus
anticoagulant or anticardiolipin antibodies
may be present. It has a propensity towards

3- Renal impairment

4- Osteoporosis

5- Hirsutism

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Answer & Comments

Answer: 4- Osteoporosis

Heparin induced thrombocytopenia,
osteoporosis and thrombosis can occur.
Warfarin can cause skin necrosis.

Answer & Comments

Answer: 4- Antiphospholipid syndrome

Apart from a thrombotic tendency,
antiphospholipid syndrome is associated with
a low white cell count and thrombocytopenia.

[ Q: 903 ] MRCPass - Haematology

A patient who is known to have
hereditary spherocytosis and has mild
jaundice and gallstones is awaiting
splenectomy.

How long prior to splenectomy should
pneumococcal voccinotion be administered?

1- 1 day

2- 5 days

3- 3 weeks

4- 3 months

5- 6 months

Answer & Comments

Answer: 3- 3 weeks

Pneumococcal immunisation should be
administered to the patient 2-4 weeks before
splenectomy.

-1

[ Q: 904 ] MRCPass - Haematology

A 28 year old woman has had a

diagnosis of pulmonary embolus. She has the
following investigations:

Haemoglobin 11.3 g/dl, white cell count 4.0 x
10 9 /l_, platelet count 45 x 10 9 /L.

Which of the following diagnoses is more
likely?

1- Homocystinuria

2- Protein C deficiency

3- Factor V leiden deficiency

4- Antiphospholipid syndrome

5- Protein S deficiency

[ Q: 905 ] MRCPass - Haematology

A 28 year old lady is 30 weeks
pregnant when she presents with a left sided
DVT. She has had a previous miscarriage
before. Her investigations show :

Hb 10.2 g/dl
MCV 68 fl
WBC 8.0 x 10 9 /L
Pits 250 x 10 9 /L

Direct Coomb's Test: positive
Reticulocyte count 90 x 10 9 /L (25-125)
APTT 51 sec (normal 28-38 sec)

PT 16 sec (normal 13-16 sec)

Protein C activity 0.75 iu/ml (0.67-1.38)
Total protein S 100% (64-154)

Which of the following diagnosis is likely?

1- Heparin induced thrombocytopenia

2- Protein C deficiency

3- Protein S deficiency

4- Factor V leiden

5- Antiphospholipid syndrome

Answer & Comments

Answer: 5- Antiphospholipid syndrome

Of the following choices, antiphospholipid
syndrome is most likely because of the
recurrent thrombotic tendency. Raised APTT
and positive Direct Coomb's test (measures
presence of antibodies on red cells) can be
caused by lupus anticoagulant.

[Iaj

[ Q: 906 ] MRCPass - Haematology

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A 32 year old woman presents with bleeding
gums and easy bruising. Her medications are
lansoprazole and cispride for reflux
oesophagitis.

Investigations show:

Haemoglobin 12.5 g/dL (13.0-16.5)

MCV 90 fl (83-95)

Platelets 35 x 10 9 /L (150-400)

Blood film : occasional giant platelets

Prothrombin time 12 s (11.5-15.5)

What is the likely diagnosis?

1- Disseminated intravascular coagulation

2- Immune thrombocytopenia

3- Thrombotic thrombocytopenic purpura

4- Megakaryocytic thrombocytopenia

5- Drug-induced thrombocytopenia

Answer & Comments

Answer: 2- Immune thrombocytopenia

This is a case of immune thrombocytopenia in
which low platelets with other counts being
normal apart from slight anaemia (due to
bleeding).

[ Q: 907 ] MRCPass - Haematology

A child has severe anaemia and been
diagnosed as having thalassemia major.

Which of the following is the major form of
haemoglobin present when the condition
exists?

1- Haemoglobin A2

2- Haemoglobin C

3- Haemoglobin F

4- Haemoglobin H

5- Haemoglobin A

Answer & Comments

Answer: 3- Haemoglobin F

In Beta-thalassaemia major there is a
complete defect in production of beta globin
chains, which leads to impaired formation of
HbA (which is made up of 2 alpha and 2 beta
chains). Haemoglobin F is the major
haemoglobin as this haemoglobin is made up
of alpha and gamma chains.

Patients with thalassemia major require
lifelong blood transfusions (hypertransfusions)
with iron chelation therapy (desferrioxamine).

[ Q: 908 ] MRCPass - Haematology

A 20-year-old man was referred for
investigation of lifelong hemolytic anemia.
Jaundice accompanied by anemia and
splenomegaly had been apparent since early
life. Episodes of jaundice were more marked
during infections or after fasting and less
pronounced following exposure to sunlight,
was conspicuous.

On investigation the following results were
obtained:

hemoglobin, 11.8 g/dL

mean corpuscular volume [MCV] 85.5 fL

mean corpuscular hemoglobin [MCH] 29.1 pg

mean corpuscular hemoglobin concentration
[MCHC] 34 g/dL

reticulocyte count 5.44

Blood film shows spherical red cells with lack
of pallor in the central area.

What is the diagnosis?

1- Anaemia of chronic disease

2- Sideroblastic anaemia

3- Megaloblastic anaemia

4- Hereditary spherocytosis

5- Iron deficiency anaemia

Answer & Comments

Answer: 4- Hereditary spherocytosis

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Hereditary spherocytosis gene for ankyrin (cell
membrane protein) has been mapped to
chromosome 8 and is autosomal dominant. It
presents in childhood with jaundice and
splenomegaly.

Treatment is with splenectomy.

Red cells are more spherical in hereditary
spherocytosis and lack the central area of

pallor.

[ Q: 909 ] MRCPass - Haematology

A 60 year old man has been on
warfarin for a DVT. He had an INR of 9 during
a follow up appointment when he was noticed
to have haematuria and epistaxis.

Whot is the appropriate management?

1- 2 units blood transfusion

2- 2 units of platelets

3- Fresh frozen plasma 1 unit

4- Stop warfarin and observe

5- 0.5 mg of vitamin K iv

Answer & Comments

Answer: 5- 0.5 mg of vitamin K iv

The patient has minor bleeding. According to
The British Society of Haematology guidelines,
when INR is > 8 with minor bleeding, warfarin
should be discontinued until the INR is < 5. IV
vitamin K 0.5 mg or oral vitamin K 5 mg should
then be given.

[ Q: 910 ] MRCPass - Haematology

A 55 year old man has had varicose
vein repair. He develops a swollen leg five

days following surgery and an ultrasound of
the leg confirms a DVT. This is despite him
having prophylactic low molecular weight
heparin.

His Hb is llg/dl, WCC 13 x 10 9 /l_, platelet
count is 45 x 10 9 /L

Which of the following could have caused the
DVT?

1- Behcet's disease

2- Factor V leiden deficiency

3- Protein C deficiency

4- Immune thrombocytopenic purpura

5- Heparin induced thrombocytopenia

Answer & Comments

Answer: 5- Heparin induced

thrombocytopenia

Type I heparin induced thrombocytopenia
(HIT) occurs within a few days of heparin and
is usually mild.

In this case, type II HIT is more likely, and this
occurs slightly later (5-15 days). It is associated
with thrombosis and a low platelet count.
Alternative anticoagulation should be used
(hirudin, danaparoid sodium).

[ Q: 911 ] MRCPass - Haematology

A 55 year old man has G6PD
deficiency. He presents with a haemolytic
crisis after a drug was started.

Which one of the following is probable?

1- Carbamazepine

2- Gentamicin

3- Paracetamol

4- Chloramphenicol

5- Phenytoin

Answer & Comments

Answer: 4- Chloramphenicol

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Haemolysis in G6PD deficiency is due to
oxidative damage (decreased generation of
NADPH due to enzyme deficiency).

The common categories of drugs are:

Sulphonamides

failure and also neurological features.
Treament of choice is plasma exchange with
fresh frozen plasma infusion. High dose
steroids may also be beneficial. Plasma
exchange removes antibodies which is the
main pathogenic problem in the disease.

Antimalarials

Antipyretics (aspirin + paracetamol)

Others : Chloramphenicol, nitrofurantoin,
Dapsone,Probenecid, Vit K

[ Q: 912 ] MRCPass - Haematology

A 32 year old woman who is 20
weeks pregnant presented with lethargy,
confusion and drowsiness.

On examination she has bilateral leg weakness
and a purpuric rash was noticed on both legs.

Investigations showed:

Hb 8.2 g/dl

WCC 7.2 x 10 9 /L

platelets 25 x 10 9 /l_

reticulocytes 3%

Urea 28 mmol/I

Creatinine 360 umol/l

Blood film showed: fragmented cells and
polychromasia

What treatment should be administered?

1- Dexamethasone

[ Q: 913 ] MRCPass - Haematology

A 23 year old woman presented very
unwell with a miscarriage. On examination,
she was very pale and breathless. She had a
blood pressure of 90/60 mmHg.

Investigations revealed:

Haemoglobin 9 g/dL

Platelets 52 x 10 9 /L

Prothrombin time 20 sec (11-15)

APTT 55 sec (30-40)

Fibrinogen 0.3 g/L (-4)

Blood film : Fragmented cells

What should be administered?

1- Intravenous hydrocortisone

2- Vitamin C

3- Tranexemic acid

4- DDAVP

5- Cryoprecipitate

Answer & Comments

Answer: 5- Cryoprecipitate

2- Plasma exchange

3- Platelet transfusion

4- Cyclophosphamide

5- Blood transfusion

Answer & Comments

Answer: 2- Plasma exchange

This patient has thrombotic thrombocytopenic
purpura as suggested by haemolysis on the
blood film, anaemia, thrombocytopenia, renal

This is a case of disseminated intravascular
coagulation (DIC) in which fibrinolytic system
becomes activated, leading to thrombin
formation. Unregulated fibrinolysis and
systemic fibrinogenolysis occurs with release
of plasmin into the circulation.

Typically, the blood film shows fragmented
red blood cells. Treatment aims to correct the
coagulopathy with blood products e.g.
cryoprecipitate to replace fibrinogen, or fresh
frozen plasma. Vitamin K can also be given in
event of significant bleeding.

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[ Q: 914 ] MRCPass - Haematology

A 55 year old patient is known to
have alcoholic liver disease. He
drinks 15 pints of beer a day and has
oesophageal varices when he had endoscopy
3 months ago. He now has melaena with the
following blood results :

Hb 7.5 g/dl
MCV 103 fl
WCC 11 x 10 9 /L

platelets 100 x 10 9 /L

PT 20 s (11.5-15.5)

APTT 40s (30-40)

Fibrinogen 0.8.0g/L (1.8-5.4)
urea 17 pmol/l

creatinine 105 pmol/l
sodium 130 mmol/I

potassium 4 mmol/I
bilirubin 62 pmol/l
AST 328 U/l
ALP 200 U/l
albumin 32 g/l

Apart from blood transfusion, which of the
following would be useful?

1- Factor VIII

2- Cryoprecipitate

3- Exchange transfusion

4- Haemodialysis

5- Albumin

Answer & Comments

Answer: 2- Cryoprecipitate

With alcoholic liver disease, there is a
prolonged PT and low platelet count. How
ever, in severe alcoholic liver disease
fibrinogen can also be lowas in this case, thus
cryoprecipitate would be useful.

[ Q: 915 ] MRCPass - Haematology

A 50 year old man presents with
hypertension. Further blood tests
reveal the following: Hb 18.6g/dl, WCC 16 x
10 9 /L, pits 600 x 10 9 /L. The erythropoietin
level is normal.

What is the most likely diagnosis?

1- Secondary polycythaemia

2- Polycythaemia rubra vera

3- Myelofibrosis

4- Gaucher's disease

5- Recombinant EPO use

Answer & Comments

Answer: 2- Polycythaemia rubra vera

In polycythaemia rubra vera, the Hb, WCC and
platelet counts are high along with a normal
EPO level. EPO is raised in secondary
polycythaemia (e.g. hypoxia).

[ Q: 916 ] MRCPass - Haematology

An 80 year old lady complains of
mild breathlessness and lethargy. She
mentions that she is a vegetarian. There is no
history of haemetemesis or melaena. She has
a past medical history of congestive cardiac
failure.

On examination, she is pale, and has vitiligo on
her hands. She has a JVP of +4 cm and fine
inspiratory crepitations.

Her investigations show :

Hb 4.5 g/dl MCV 105

WBC 3.3 x 10 9 /L Pits 120 x 10 9 /L

What is the most important initial
management?

1- Blood transfusion

2- Start vit B12 and folic acid

3- Red cell mass studies

4- Bone marrow aspirate

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5- Schilling test

Answer & Comments

Answer: 2- Start vit B12 and folic acid

Pancytopenia and raised MCV suggests severe
B12 or folate deficiency. Vitiligo is also a clue
as to autoimmune phenomenon, and
pernicious anaemia may be associated. In this
lady, blood transfusion may exacerbate
cardiac failure, and she is not actively
bleeding, hence replacement of B12 and
folate is a better option (symptoms will
improve within 1-2 weeks).

B12 deficiency can occur as a result of
pernicious anaemia (intrinsic factor
deficiency), dietary e.g. vegetarian, Crohns
disease, Serum folate level less than 5 ng/ml
or serum vitamin Bi 2 level less than 100 pg/ml
is diagnostic.

Folate deficiency is treated by giving folic acid
orally at 1 to 5 mg daily. B12 deficiency is
usually treated by parenteral administration
of B12. The treatment schedule consists of
giving 1000?g cobalamin intramuscularly daily
for 10 - 14 days follw ed by 1000 ?g once a
week till hematocrit becomes normal followed
by 1000 ?g once a month for life in patients
with pernicious anemia or those with
malabsorption. Therapeutic doses of folate
will correct the hematologic abnormalities due
to cobalamin deficiency also but the
neurologic abnormallities can w orsen, it is
best to give B12 first or both B12 and folate
but never folate alone.

[ Q: 917 ] MRCPass - Haematology

A 50 year old woman presented with
a five year history of pain in the middle of
both feet. She also had a history of back pain,
pain in both sides of her hip, and pain in both
metacarpals.

She had a serum ferritin concentration of
1087 pg/l, with normal results in liver function
tests and a normal glucose concentration, full

blood count, and erythrocyte sedimentation
rate.

Whot is the diagnosis?

1- Wilson's disease

2- Ochronosis

3- Marble bone disease

4- Haemochromatosis

5- Thalassemia

Answer & Comments

Answer: 4- Haemochromatosis

Haemochromatosis has an autosomal
recessive pattern of inheritance and affects 1
in 250 of the northern European population,
with up to 10% of people carrying the gene.
Inheritance of the disease has long been
associated with the tissue type HLA A3. A
specific mutation of the gene, C282Y is
common.

The clinical presentation of

haemochromatosis is variable and not
confined to the classic triad of cirrhosis,
diabetes, and skin pigmentation. In this case
the presentation is with arthropathy.

[ Q: 918 ] MRCPass - Haematology

A 56 year old man was diagnosed
with myelofibrosis.

Which of the following is the most common
presentation of the disease?

1- Bleeding

2- Respiratory pain

3- Hyperuricaemia

4- Fatigue

5- Bone pain

Answer & Comments

Answer: 4- Fatigue

Clinical features of myelofibrosis include:

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usually develops in adults over age 50 patients
commonly present with fatigue and weakness
spleen is often massively enlarged
hepatomegaly occurs in over half of cases

[ Q: 919 ] MRCPass - Haematology

A 60 year old woman was admitted
with a 10-month history of rash, fatigue,
intermittent hemoptysis, and purpura. On
admission, widespread petechiae and purpura
with scleral icterus were noted. No
lymphadenopathy or splenomegaly was
present.

Investigations showed:
platelet count of 3 x 10 9 /L
hemoglobin level 5.5 g/dL
mean corpuscular volume 103 fL
white cell count 3.6 x 10 9 /L
neutrophils at 0.67 without myeloid blasts
reticulocyte count was 0.20
serum urea 15.4 mmol/L (43 mg/dL)
creatinine, 239 pmol/L
lactate dehydrogenase (LDH) 2505 U/L
total bilirubin 19 pmol/L (4.6 mg/dL)
haptoglobin, 6 g/L

Review of the peripheral smear revealed
notable red cell morphology and 24 nucleated
red blood cells per 100 white blood cells,
many of which were dysplastic.

What is the most likely diagnosis?

1- Idiopathic thrombocytopenic purpura

2- Thalassemia

3- Sickle cell disease

4- Myelodysplasia

5- Chronic myeloid leukaemia

Answer & Comments

Answer: 4- Myelodysplasia

'"'There is a gradual history of progression and
the patient has a pancytopenia, she is also in
the right age group for myelodysplasia.
Myelodysplasia can be classified into five
subtypes -

Refractory anaemia

Refractory anaemia with ring sideroblasts

Refractory anaemia with excess blasts

Refractory anaemia with excess blasts in
transformation (near AML)

CML.

Few patients require aggressive therapy such
as chemotherapy, it is reserved for younger
patients to prevent progression to AML.
Supportive therapy includes blood
transfusions, platelet transfusions or G-CSF to
improve blood counts. How ever median
survival is only 2 years.

[ Q: 920 ] MRCPass - Haematology

An 18 year old girl presents with
epistaxis. She is found to have a prolonged
APTT. Her Mother has had previous bleeding
episodes with similar coagulation test results.

What is the most likely diagnosis?

1- Factor VII deficiency

2- Factor V deficiency

3- Protein C deficiency

4- Von Willebrand's disease

5- Haemophilia B

Answer & Comments

Answer: 4- Von Willebrand's disease

The APTT is a general clotting screen which
detects defects in the intrinsic clotting
pathway (factors XII, XI, IX, and VIII, to which
Von Willebrand factor is linked). Von
Willebrand's disease is a predominantly
autosomal dominant condition which is

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associated with a bleeding tendency, which is
usually mild and with a prolonged APTT.

The tests to diagnose vWD include:

1- Fresh frozen plasma

2- Factor X

3- Factor IX

bleeding time (prolonged)

factor VIII level test (measures the level of
factor VIII and its ability to function)

von Willebrand factor antigen test (the
disorder is considered mild if a person has
20% to 40% of the normal amount, severe if
the amount is less than 10% of normal)

ristocetin cofactor activity test (measures how
well the von Willebrand factor is working)

4- Aspirin

5- DDAVP

Answer & Comments

Answer: 5- DDAVP

Treatment may include Desmopressin
(DDAVP), Factor VIII and tranexemic acid in
von Willebrand's disease.

1 W J

[ Q: 923 ] MRCPass - Haematology

[ Q: 921 ] MRCPass - Haematology

A 15 year-old boy presented to clinic
6 month history of anorexia and

A patient presents with acute

with a

promyelocytic leukaemia.

What is the likely mechanism underlying
leukaemogenesis?

1- Aberrant fusion of 2 genes

2- Posttranslational modification

malaise. On examination, he had palpable
inguinal lymphadenopathy and splenomegaly.

Investigations show : Hb 13.1 g/dl

White cell count 20 x 10 9 /L

erythrocyte sedimentation rate 15 mm/h

3- Over expression of cellular oncogene

4- Impaired degradation of protein

5- Short telomere

Answer & Comments

Answer: 1- Aberrant fusion of 2 genes

Acute promyelocytic leukaemia is frequently
due to chromosomal translocation t (15; 17).

Peripheral blood film showed: atypical
lymphocytes, blast cells and neutropenia

What is the most likely diagnosis?

1- Aplastic anaemia

2- Acute myeloid leukaemia

3- Chronic myeloid leukaemia

4- Paroxysmal nocturnal haemoglobinuria

5- Acute lymphoblastic leukaemia

[ Q: 922 ] MRCPass - Haematology

A 15 year old male comes to the
hematology clinic for his specialty care for von
Willebrand Disease. The past medical history
reveals that he was diagnosed with Type 1 von
Willebrand Disease as a toddler after
abnormal bruising and prolonged bleeding
was noted by his family.

What treatment is recommended if he were to
have a significant episode of bleeding?

Answer & Comments

Answer: 5- Acute lymphoblastic leukaemia

Blast cells on the blood film and a
lymphocytosis would suggest acute
lymphoblastic leukaemia. The malignant cells
are immature lymphoid blast cells. The patient
with acute lymphoblastic leukaemia is usually
a child.

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Bone Marrow biopsy showing predominant

lymphoblasts

[ Q: 924 ] MRCPass - Haematology

A 25 year old woman has the
following investigations at the antenatal clinic:

Hb 10.3 g/dl

WBC 5.6 x 10 9 /L

Pits 290 x 10 9 /L

MCV 69 fl

MCH 17.2

Iron 20 (14-29) pmol/l

Ferritin 150 (15-200) ?mol/l

What is the most useful investigation?

1- Myeloma screen

2- Haemoglobin electrophoresis

3- Folate levels

4- HbF level

5- HbA2 level

Answer & Comments

Answer: 5- HbA2 level

Iron deficiency anaemia and thalassaemia trait
are the most likely diagnoses of microcytic
anaemia. Iron deficiency is unlikely in this case
in view of the iron studies being normal. Beta
thalassaemia trait is diagnosed by the
presence of a raised HbA2. If both conditions
are excluded, then alpha thalassaemia is the
most likely diagnosis.

[ Q: 925 ] MRCPass - Haematology

A 30 year old lady with von
Willebrand's disease is due to have plastic
surgery to her face and seeks advice from the
haematologist. She mentions that she has a
history of epistaxis and bleeding gums.

Which of the following is the most useful
assessment of her coagulation status?

1- Prothrombin time

2- Activated partial thromboplastin time

3- Thrombin time

4- Bleeding time

5- Factor VIII activity assay

Answer & Comments

Answer: 5- Factor VIII activity assay

Although bleeding time is prolonged in von
Willebrand's disease, the factor VIII activity
assay will give a measurement of the severity
of her disease. The other useful tests would be
the ristocetin cofactor assay and vWF antigen
assays for von Willebrand's disease.

[ Q: 926 ] MRCPass - Haematology

A 20 year old patient has been found
to have a mediastinal mass on the
chest X ray during investigation for a

pneumonia.

He has a Hb of 12 g/dl, WCC 180 x 10 9 /L,
platelets 45 x 10 9 /L.

Blood film shows blast cells with have
prominent nucleoli.

There is little cytoplasm within the white cells,
and the nucleoli are convoluted.

Which is the likely diagnosis?

1- Acute myeloid leukaemia

2- Acute lymphoblastic leukaemia

3- Multiple myeloma

4- Hodgkin's lymphoma

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5- Non Hodgkin's lymphoma

Answer & Comments

Answer: 2- Acute lymphoblastic leukaemia

There is a very high white cell count which
should make leukaemia suspicious. ALL occurs
in childhood and young adulthood. The blood
film described above distinguishes ALL from
AML (contains elongated inclusions called
Auer rods).

Multiple lymphoblasts in ALL

[ Q: 927 ] MRCPass - Haematology

A 25 year old lady who was pregnant
was treated for a deep vein thrombosis with
intravenous heparin. A recent test shows:

Haemoglobin 10.2 g/dL

White Cell Count 8 x 10 9 /L

Platelets 32 x 10 9 /L

Whot is the best course of action this woman?

1- Change to clexane

2- Commence warfarin

3- Change to aspirin

4- Change to danaparinoid

5- Continue iv heparin

Answer & Comments

Answer: 4- Change to danaparinoid

This patient has Heparin Induced
Thrombocytopaemia. When HIT is suspected,
heparin treatment should be converted to
danaparoid , which is a low molecular weight

heparinoid. It is usually given as an
intravenous infusion

[ Q: 928 ] MRCPass - Haematology

A 65 year old man complains of
breathlessness and tiredness. He has
confirmed pulmonary emboli. His Hb is 18
g/dl, WCC is 15 x 10 9 /L and platelet count is
700 x 10 9 /l.

Which of the following can be helpful in
confirming the diagnosis?

1- Blood film

2- Bone marrow biopsy

3- Red cell mass

4- NAP score

5- Kleihauer test

Answer & Comments

Answer: 3- Red cell mass

The diagnosis is polycythaemia rubra vera and
this can be confirmed by a raised red cell
mass. NAP score is decreased in CML. A
Kleihauer test is used to confirm
transplacental blood loss from fetus to
mother.

[ Q: 929 ] MRCPass - Haematology

A 50 year old man with non
Hodgkin's lymphoma is on Rituximab.

Which of the following antigens does
Rituximab have an action on?

1- CD8

2- CD8

3- CD19

4- CD20

5- CD154

Answer & Comments

Answer: 4- CD20

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Rituximab is an antibody to CD20 expressed
on B cells and is used in B cell lymphomas (to
try to cause cell lysis). The receptor is present
in more than 90% of B-cell non-Hodgkin's
lymphomas. Molecules that attach to CD20
can affect the growth and development of the
tumor cells. Rituximab is an antibody that was
developed using cloning and recombinant
DNA technology from human and murine
genes.

[ Q: 930 ] MRCPass - Haematology

A 32 year old who is known to have
ITP presents with bleeding of her gums. Her
platelet count normally runs at 87 x 10 9 /l_ but
now has dropped to 42 x 10 9 /L.

What is the best management plan?

1- Observation

2- Steroids

3- Platelet transfusion

4- FFP

5- Whole blood transfusion

Halfway through the first unit of blood, she
experiences generalised discomfort.

What is the most appropriate course of
action ?

1- Chest X ray and abdominal x ray

2- Blood cultures

3- Give analgesia and continue

4- IV steroids

5- Stop the blood transfusion and give IV fluids

Answer & Comments

Answer: 5- Stop the blood transfusion and give
IV fluids

Acute transfusion reactions can cause
generalized discomfort, loin pain and pain at
the cannula site may all precede
haemoglobinuria and renal failure. If a
transfusion reaction is suspected, the
transfusion should be stopped immediately
and IV fluids should be administered, to
prevent shock.

Answer & Comments

Answer: 2- Steroids

Chronic ITP rarely resolves spontaneously.
First line treatment is with prednisolone.
Patients with chronic ITP who require surgery
may be given intravenous immunoglobulins
which produce a transient rise in platelet
count by blocking Fc receptors on splenic
macrophages.

Platelet transfusion should be given only in
life-threatening haemorrhage to enhance
haemostasis.

[ Q: 931 ] MRCPass - Haematology

A 45 year old woman presents with
an upper Gl bleed and requires a blood
transfusion.

[ Q: 932 ] MRCPass - Haematology

A 55 year old man enquires about
risks of blood transfusion.

Which of the following infections is blood
screened for?

1- Varicella zoster

2- Hepatitis B

3- Cytomegalovirus

4- Malaria

5- Salmonella

Answer & Comments

Answer: 2- Hepatitis B

CMV, malaria and salmonella can all be
transmitted by blood products.

In the UK, routine testing for donor blood is
for:

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HIV

Hep B&C
Syphilis
ABO + RhD

[ Q: 933 ] MRCPass - Haematology

A 60 year old man presents with
extensive bruising. He has a history of fatigue
and dizziness for the past few months. On
examination, he has a purpuric rash on his
trunk and limbs. Investigations show :

Hb 7.5 g/dl

MCV 105 fl

WCC 7 x 10 9 /L

platelets 100 x 10 9 /L

Prothrombin time 20 (12-17)s

Fibrinogen 90 (150-460) mg/dL

Blood film: 50% blast cells.

What is the clinical picture consistent with?

1- Erythroleukaemic reaction

2- Aplastic anaemia

3- Disseminated intravascular coagulation

4- Haemolytic anaemia

5- Immune thrombocytopenic purpura

associated with DIC. In leucoerythroblastic
picture, nucleated red cells and white cell
precursors are found in the peripheral blood.

[ Q: 934 ] MRCPass - Haematology

A 60 year old woman has had a
prolonged ITU stay due to severe pneumonia
and sepsis requiring mechanical ventilation.
She was noted to have worsening anaemia
following discharge from ITU at 4 weeks. Her
Hb is 6 g/dl, MCV 109 fl, WCC 2.2 x 10 9 /L,
platelets 110 x 10 9 /L.

What is the likely cause of anaemia?

1- Upper Gl bleed

2- Aplastic anaemia

3- Acute myeloid Leukaemia

4- Immune thrombocytopenic purpura

5- Acute folate deficiency

Answer & Comments

Answer: 5- Acute folate deficiency

A patient who has been in intensive care for a
significant period may not be getting enough
folate, especially with increased needs for
recovery. An acute deficiency state may thus
develop. This would precipitate a
pancytopenia and macrocytic anaemia.

Answer & Comments

[ Q: 935 ] MRCPass - Haematology

Answer: 3- Disseminated intravascular

^ J

A 20 year old female presents with

coagulation

The clinical diagnosis is likely to be acute
myeloblastic leukaemia (AML). AML subtypes
are distinguished from other related blood
disorders by the presence of more than 30%
blasts in the blood, bone marrow , or both.
One of the common complications is DIC,
which results in an elevated prothrombin
time, decreased fibrinogen level and increased
fibrin degradation products. Acute
promyelocytic leukemia (APL), also known as
M3, is the most common subtype of AML

severe colicky abdominal pain, vomiting and
constipation of 3 days duration.

She had a previous history of admission to
hospital with similar features.

Her abdominal x-ray and ultrasound scan were
normal. She was treated with antibiotics,
analgesics and antiemetics. Her urine was
discoloured and she had a tonic- clonic seizure
whilst on the ward.

What is the likely diagnosis?

1- Variegate porphyria

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2- Acute intermittent porphyria

3- Fabry's disease

4- Gaucher's disease

5- Mature onset diabetes of the young

Answer & Comments

Answer: 2- Acute intermittent porphyria

Acute intermittent porphyria is autosomal
dominant disorder caused by a defect in
porphobilinogen deaminase activity. If
peripheral neuropathy, such as pain in the
back and legs or parathesias occurs it is almost
always preceded by abdominal pain.

Other autonomic neuropathies that may be
seen are sweating, vascular spasm, labile
hypertension, and sinus tachycardia. Central
nervous dysfunction can be seen as well with
seizures, coma, bulbar paralysis, or cerebellar
involvement.

The defect in porphobilinogen deaminase
causes a build up of ALA and porphobilinogen
(PBG) which causes their increased secretion
in the urine.

[ Q: 936 ] MRCPass - Haematology

A 35 year old lady has had frequent
menorrhagia over the last few months. She
feels well but looks pale on examination.

Investigations reveal:

Hb 8.6 g/dl

MCV 70 fl

MCHC27 (32-35) g/dl

WCC 7 x 10 9 /L

platelets 225 x 10 9 /L

Iron 9 (14-29) pmol/l

Ferritin 12 (15-200) ?mol/l

total iron binding capacity 95 (45-72) umol/l

What feature is likely to be found on the blood
film?

1- Fragmented cell

2- Helmet cell

3- Polychromasia

4- Spherocytes

5- Target cells

Answer & Comments

Answer: 5- Target cells

This lady has iron deficiency anemia. Common
blood film features are pencil cells, target cells
and pokilocytosis.

Causes of target cells are liver disease, post
splenectomy, iron deficiency and thalassemia.

Target Cells

[ Q: 937 ] MRCPass - Haematology

A 50 year old man has a history of
epistaxis. He is also generally very tired. On
examination, he has no lymphoadenopathy or
splenomegaly.

His blood tests reveal:

Hb 7.6 g/dl

MCHC 32 g/dl (32-35)
Neutrophils 1.5 x 10 9 /L
urea 8 pmol/l
sodium 143 mmol/l
bilirubin 25 pmol/l
ALP 150 U/l
LDH 120 U/l (10-250)

MCV 90 fl
WCC 3 x 10 9 /L
platelets 29 x 10 9 /L
creatinine 125 pmol/l
potassium 3.6 mmol/l
AST 18 U/l
albumin 32 g/l

Which of the following investigations would be
most helpful?

1- CT of abdomen

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2- Genetic studies

3- PET scan

4- Bone marrow aspiration and cytology

5- Bone marrow biopsy

Answer & Comments

Answer: 5- Bone marrow biopsy

On the blood tests, there is aplastic anaemia
which chould be due to infiltration by a
tumour, autoimmune or drug induced.
Although both bone marrow aspiration is
useful, a biopsy is required to assess cellularity
and to exclude abnormal infiltration due to a
mlaignant process. In aplastic anaemia,
erythropoietic cells, megakaryocytes and
granulocytic cells are reduced.

Bone marrow aspiration involves aspirating
fluid contents of marrow w hilst bone marrow
biopsy involves more force to obtaine bone
morrow core. See pictures:

Aplastic Anaemia - Bone Marrow Biopsy

5- Iron infusion

Answer & Comments

Answer: 4- Packed red cells

The patient who is anaemic and bleeding
needs a blood transfusion with packed red
cells (blood). This also contains some white
cells, platelets & a small amount of plasma
plus 60 -100 ml of additive.

[ Q: 939 ] MRCPass - Haematology

A 75 year old woman with chronic
myeloid leukemia (CML), treated with
hydroxyurea and interferon for 12 years
suffered from gradual disease progression for
one year.

Investigations show :

Haemoglobin 11.6 g /dL

white cell count 47 x 10 9 /L (neutrophils, 80%;
lymphocytes, 13%; metamyelocytes, 6%;
blasts, 1%)

platelet count 1220 x 10 9 /L

Whot should the patient be treated with?

1- Cyclophosphamide

2- Prednisolone

3- Radiotherapy

4- Desferrioxamine

5- Imatinib

^ [ Q: 938 ] MRCPass - Haematology

* A 45 year old woman presents with
haemetemesis. She has a haemoglobin (Hb) of
4.5 g/dL and platelet count of 350 x 10 9 /L.

Which of the following is the most appropriate
product or drug to use?

Answer & Comments

Answer: 5- Imatinib

Gleevec (imatinib mesylate, Novartis), is an
oral drug which interferes with the action of
the abnormal Bcr-Abl tyrosine kinase in CML
white blood cells.

1- Fresh frozen plasma (FFP)

2- Iv methylprednisolone

3- Plasma protein fraction

Before Gleevec, the most common drugs used
to treat CML were the oral treatments
hydroxyurea and busulphan.

4- Packed red cells

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An intravenous treatment, cytarabine, is
sometimes used in combination with immune
therapy (interferon). Bone marrow or stem
cell transplantation tends to be limited to
younger patients.

[ Q: 940 ] MRCPass - Haematology

A 30 year old woman is being
investigated for right upper quadrant pains.
She reports occasional episodes of jaundice,
especially associated with infections. Her
mother, sister and aunt has previously had
gallstones. On examination, she has
splenomegaly. Her FBC is normal, but her
bilirubin is mildly elevated.

What is the likely cause for her probable
gallstones?

1- Sickle cell disease

2- Hereditary spherocytosis

3- Beta thalassemia

4- Gilbert's syndrome

5- Paroxysmal nocturnal haemoglobinuria

Answer & Comments

Answer: 2- Hereditary spherocytosis

Hereditary spherocytosis is inherited in an
autosomal dominant fashion. It is
characterised by increased red cell fragility.
There is increased haemolysis during
infections. Gallstones are commonly
associated. Management is usually supportive,
although some cases require splenectomy to
reduce transfusion requirements.

Spherical red cells in hereditary spherocytosis

[ Q: 941 ] MRCPass - Haematology

A 30 year old patient has significant
Gl bleeding, but is concerned about the risks
of blood transfusion.

Which of the following is screened for in
donated blood?

1- JC virus

2- Human T cell leukaemia virus

3- HIV-1

4- New variant CJD

5- Toxoplasmosis

Answer & Comments

Answer: 3- HIV-1

In the UK every blood donation is tested for
evidence of hepatitis B, hepatitis C, HIV-1, HIV-
2 and syphilis. How ever, although there are
recent concerns regarding tranmission of new
variant CJD, there are no reliable screening
methods yet.

^ [ Q: 942 ] MRCPass - Haematology

# A 35 year old woman with a

haematological condition has been transfused
with group specific platelets on several
occasions. Her platelet count drops quickly 5
days following platelet transfusion.

What should she be treated with?

1- Fresh frozen plasma

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2- Cryoprecipitate

3- Packed red cells

4- Intravenous immunoglobulin

5- Factor VIII

Answer & Comments

Answer: 4- Intravenous immunoglobulin

Post transfusion purpura is a transfusion
reaction occurring occurs 5 - 14 days after
transfusion of platelets or fresh frozen plasma.
This occurs when individuals lacking the PLA-1
antigen are transfused with blood containing
PLA-1 positive platelets. It is uncommon as
only 2-3% of the population are PLA-1
negative.

Treatment of choice is intravenous
immunoglobulin or plasma exchange. Further
platelet transfusions should be w ashed or be
HPA-1A negative.

[ Q: 943 ] MRCPass - Haematology

A 70 year old female presents with
left upper quadrant pain and multiple
ecchymoses (bruising).

Investigations:

hemoglobin 9.5 g/dL

platelet count 30 x 10 9 /L

white cell count of 8.2 x 10 9 /L

The bone marrow biopsy is hypercellular
(75%) and shows diffuse infiltration by large
atypical cells with abundant cytoplasm.

What is the diagnosis?

1- Acute myeloid leukaemia

2- Chronic lymphocytic leukaemia

3- Hodgkin's lymphoma

4- Waldenstrom's macroglobulinaemia

5- Polycythaemia rubra vera

Answer & Comments

Answer: 2- Chronic lymphocytic leukaemia

Chronic lymphocytic leukaemia arises from
the neoplastic proliferation of relatively
mature lymphocytes which infiltrate the
blood, bone marrow or lymphoreticular
structures. Most are clonal malignancies of B
lymphocytes rather than T lymphocytes. Bone
marrow aspiration / biopsy - typically there is
infiltration by lymphocytes.

Diffuse infiltration by large atypical cells in CLL

[ Q: 944 ] MRCPass - Haematology

A 35 year old man who works in a
factory has accidentally drunk a large amount
of dye. He is brought to the hospital looking a
blue colour.

His Hb is 16 g/dl. Blood gases show a pH of
7.37, p0 2 of 13 kPa, pC0 2 of 4.5 kPa and 0 2
sats of 80% on the sats monitor.

Which is the diagnosis?

1- Methaemoglobinaemia

2- Down's syndrome

3- Fallot's tetralogy

4- Carbon monoxide poisoning

5- Polycythaemia rubra vera

Answer & Comments

Answer: 1- Methaemoglobinaemia

Methaemoglobinaemia is the most likely
diagnosis due to ingestion of aniline dye in this
case. The p02 is often normal but the oxygen
saturations are reduced in

methaemoglobinaemia.

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^ [ Q: 945 ] MRCPass - Haematology

fh -

* A 40 year old woman has a long
history of anaemia, and is not compliant with
medications.

Investigations show :

Haemoglobin 7.8 g/dL (11.3-16.5)

MCV 85 fl (80-96)

MCH 26 pg (28-32)

WCC 7 x 10 9 /L

Platelets 160 x 10 9 /L

Serum B12 130 ug/L (160-760)

Red cell folate 95 ug/L (160-640)

Serum ferritin 11 ug/L (15-300)

Which of the following antibodies is likely to
be present with the condition?

1- Antigliadin antibody

2- Anti intrinsic factor antibody

Hct 0.612

Platelet count 468 x 10 9 /L
ESR 1 mm/lst hour
coagulation screen normal
What is the diagnosis?

1- Essential thrombocythaemia

2- Chronic myeloid leukaemia

3- Polycythaemia rubra vera

4- Idiopathic thrombocytopenic purpura

5- Thalassemia

Answer & Comments

Answer: 3- Polycythaemia rubra vera
The criteria for PRV are:

1) increased red cell mass

2) splenomegaly

3- Anti parietal cell antibody

4- Anti nuclear antibody

5- Anti phospholipid antibody

Answer & Comments

Answer: 1- Antigliadin antibody

There are mixed iron and folate deficiency due
to coeliac disease. This causes a normal MCV
(dimorphic picture because of both micro and
macrocytic features). Antibodies which are
present in coeliac disease are : antiendomysial
and antigliadin. vitamin Bn concentrations
normalize on a gluten-free diet alone, but
symptomatic patients may require
supplementation.

3) increased platelets, leucocytes, INCREASED
NAP score and B12 (increased B12 binding
protein release).

Gout occurs due to increased cell turnover,
cerebral and myocardial ischaemia occurs due
to fall in perfusion and raised blood viscosity.

The NAP score is a semiquantitative
cytochemical assessment of alkaline
phosphatase in neutrophils. The NAP score is
based on staining intensity, with a possible
score of 0-400. It differentiates chronic
myeloid leukaemia (low) from reactive
leucocytosis (high), eg bacterial infection. It
may assist in the differentiation of
polycythaemia rubra vera (high) from other
causes of erythrocytosis (normal).

[ Q: 946 ] MRCPass - Haematology

A 60 year old lady is investigated for
recurrent episodes of gout. On examination,
she looked plethoric and has a 6 cm
splenomegaly. She has the following results:

Hb 18.9 gm/dl

[ Q: 947 ] MRCPass - Haematology

A 25 year old woman presented to
the hematology clinic with a 5 year history of
pallor and anemia. On physical examination,
the patient was found to have mild
splenomegaly.

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Results show:

Hemoglobin 7.9 g/dL
platelet count of 226 x 10 9 /L
MCV 68 fl

MCH was 20 pg (24.0-31.0 pg)

MCHC 30.1 g/dL (32.0-36.0 g/dL)

serum iron 31.6 ?mol/L (9.0-26.9)

ferritin 380 ng/mL (22-400 ng/mL)

transferrin 161 mg/dL (185-370 mg/dL)

Bone marrow aspirate demonstrated
significant hypercellularity associated with
marked erythroid hyperplasia.

Stainable iron stores were increased. A
striking feature was the presence of numerous
blasts in which the perinuclear iron granules
encircled more than one third of the nuclear
circumference.

What is the diagnosis?

1- Haemochromatosis

2- Sideroblastic anaemia

3- Multiple myeloma

4- Waldenstrom's macroglobulinaemia

5- Thalassemia

Answer & Comments

Answer: 2- Sideroblastic anaemia

Sideroblasts are abnormal red cell precursors
with iron loaded mitochondria, forming a ring
around the nucleus. Sideroblastic anaemia is
associated with alcohol, lead, drugs and
myelodysplasia. There is a defect in haem
synthesis, thus excess loading of iron to
compensate in red cell precursors and into
iron stores, sometimes causing
haemosiderosis in the liver, and
desferrioxamine therapy may help.

Ringed sideroblasts are precursors and hence
are found in the bone marrow . Anti
tuberculous drugs interfere with haem
metabolism by interefering with pyridoxine

availability. Some cases respond to pyridoxine
therapy (not panthotenic acid).

[ Q: 948 ] MRCPass - Haematology

fft

m A 15 year old Filipino girl is noted to
have a hemoglobin of 10.6 g/dl with an MCV
of 65 fl on routine testing.

She reports regular menses lasting 4-5 days
each cycle. She has no specific complaints. She
is unaw are of a family history of anemia. On
examination, there is no hepatosplenomegaly,
jaundice, or scleral jaundice.

What is the likely diagnosis?

1- Iron deficiency

2- Lead poisoning

3- Thalassemia

4- Sickle cell anaemia

5- Acute lymphoblastic leukaemia

Answer & Comments

Answer: 3- Thalassemia

This patient is likely to have thalassemia trait
(probably alpha thalassemia). Those with
alpha thalassemia trait are clinically normal,
but their hemoglobin is slightly low and their
hemogram demonstrates microcytic indices.

[ Q: 949 ] MRCPass - Haematology

A 50 year old woman has a life-long
history of anemia. Her mother has a similar
history. Laboratory values show

Haemoglobin 10.5 g/dl

Haematocrit 33

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MCV 66 fl

Blood film: microcytic, normochromic red
cells. A fewelliptocytes and target cells are
noted.

Which of the following is the most likely
condition?

1- Iron deficiency anaemia

2- Hereditary spherocytosis

3- Thalassemia

4- G6PD deficiency

5- Autoimmune haemolytic anaemia

Answer & Comments

Answer: 3- Thalassemia

This patient has either thalassemia trait or
beta thalassemia minor. Mutations in globin
genes cause thalassemias. Alpha thalassemia
affects the alpha-globin gene(s). Beta
thalassemia affects one or both of the beta-
globin genes. In beta thalassemia major (ie,
homozygous beta thalassemia), the
production of beta-globin chains is severely
impaired, because both beta-globin genes are
mutated. In beta thalassemia minor, one of
the beta-globin chains is impaired.

The severe anemia resulting from this disease,
if untreated, can result in high-output cardiac
failure, which causes the highest mortality.

Blood film showing target cells (low er left and
upper right Conner as well as elliptocyte in the

lower left)

[ Q: 950 ] MRCPass - Haematology
A 48 year old male was referred for

investigation of anemia.

Reults show :

hemoglobin of 7.2 g/dL

a white blood cell count of 3 x 10 9 /L

platelet count of 60 x 10 9 /l_

On physical exam, his spleen was enlarged.

Peripheral blood showed teardrops and a
leukoerythroblastic smear. Bone marrow
biopsy showed increased numbers of
megakaryocytes and grade III fibrosis.

What is the diagnosis?

1- Folate deficiency anaemia

2- Coomb's positive haemolytic anaemia

3- Myelofibrosis

4- Multiple myeloma

5- Chronic myeloid leukaemia

Answer & Comments

Answer: 3- Myelofibrosis

In myelofibrosis, splenomegaly occurs with a
fibrotic process. Haemolytic anaemia is not
typically steroid responsive.

Leucoerythroblastic anaemia (red cell and
white cell precursors) are seen on the blood
film. Bone pain, bleeding (platelet
dysfunction) may occur but are not
characteristic. Fibrous tissue infiltration of the
bone makes it difficult to aspirate bone
marrow .

Marrow biopsy demonstrating sigificant

fibrosis

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[ Q: 951 ] MRCPass - Haematology

A 16 yearold boy with sickle cell
disease complains of acute breathlessness. He
has a respiratory rate of 35 breaths per
minute. O 2 saturations are 75% on room air
and 85% on 100% oxygen. There is reduced air
entry bilaterally, but no added sounds.
Investigations show :

p0 2 6.2 kPa

CXR: bilateral basal infiltrates

[ Q: 952 ] MRCPass - Haematology

A 35 year old patient has
schizophrenia. He is on clozapine, temazepam
and amoxycillin for a recent chest infection.

He is admitted unwell the following blood
results:

Hb 2.0 g/dl, WCC 2 x 10 9 /L, Neutrophils 0.3 x
10 9 /L, platelets 180 x 10 9 /L, urea 6 mmol/l,
creatinine 80 mmol/l, sodium 140 mmol/l,
potassium 3.8 mmol/l.

Hb 7.5 g/dl

WCC 14 x 10 9 /L

platelets 200 x 10 9 /L

The most appropriate management is:

1- IV antibiotics

2- Non invasive ventilation

3- IV fluids

4- Blood transfusion

5- Urgent exchange transfusion

Which of these is likely to be the cause of
neutropenia?

1- Clozapine

2- Amoxycillin

3- Myelofibrosis

4- Myeloma

5- Sepsis

Answer & Comments

Answer: 1- Clozapine

Answer & Comments

Answer: 5- Urgent exchange transfusion

The diagnosis is acute chest syndrome. The
acute chest syndrome (ACS) in sickle cell
disease (SCD) can be defined as:

1. a new infiltrate on chest x-ray

2. associated with one or more NEW
symptoms: fever, cough, sputum production,
dyspnea, or hypoxia.

Exchange blood transfusions are indicated in
cases of cerebrovascular accidents and acute
chest syndrome.

They are performed occasionally in patients
with acute sequestration crisis or in cases of
priapism that do not resolve after adequate
hydration and analgesia . Exchange
transfusion consists of replacing the patient's
RBCs by normal donor RBCs, decreasing HbS
to less than 30%.

Clozapine is associated with neutropenia and
agranulocytosis are main haematological
complications. Severe neutropenia can be
treated with G-CSF.

[ Q: 953 ] MRCPass - Haematology

A 30 year old male presents with
painless cervical and axillary
lymphadenopathy. He also complains of fever
and pruritus. Lymph node biopsy
demonstrates Reed-Sternberg cells.

Which feature would indicate the worst
prognosis?

1- Sweating

2- Inguinal lymphadenopathy

3- Bone marrow involvement

4- Pruritus

5- Fever

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Answer & Comments

Answer: 3- Bone marrow involvement

The patient has Hodgkin's disease.
Involvement of the bone marrow would
classify the patient as stage IV (modified Ann
Arbor classification) indicating poor prognosis.

* Stage I is involvement of a single lymph node
region (I) or single extralymphatic site (le)

* Stage II is involvement of two or more lymph
node regions on the same side of the
diaphragm (II) or of one lymph node region
and a contiguous extralymphatic site (lie)

* Stage III is involvement of lymph node
regions on both sides of the diaphragm, which
may include the spleen (Ills) and/or limited
contiguous extralymphatic organ or site (llle,
llles)

* Stage IV is disseminated involvement of one
or more extralymphatic organs

Reed Sternberg cell showing prominent

nucleoli

[ Q: 954 ] MRCPass - Haematology

A 25 year old lady has a mother who
has had a splenectomy for anaemia. She
presents unwell with abdominal pain and
vomiting. Examination reveals a tender right
upper quadrant and jaundice, as well as 4 cm
splenomegaly.

Her bloods show :

Hb 9.0 g/dl MCV 95 fl

MCHC 33 g/dl (32-35) WCC 11 x 10 9 /L

platelets 200 x 10 9 /L

10 9 /L (50-100)

reticulocytes 180 x
urea 5.5 pmol/l
sodium 137 mmol/l
bilirubin 48 pmol/l
ALP 450 U/l
LDH 650 U/l (10-250)

creatinine 65 pmol/l
potassium 4.2 mmol/l
AST 60 U/l
albumin 38 g/l

Which one of the following is the likely
diagnosis?

1- Autoimmune haemolytic anaemia

2- Pancreatitis

3- Hereditary spherocytosis

4- Sickle cell disease

5- Acute myeloid leukaemia

Answer & Comments

Answer: 3- Hereditary spherocytosis

Hereditary spherocytosis is most likely due to
the family history and presentation. The blood
tests show likely haemolysis. The history also
suggests cholecystitis due to gallstones.

Gallstones occur in patients with recurrent
haemolysis (pigmented stones).

Spherocytes are small, round erythrocytes
that lack central pallor (arrow s)

[ Q: 955 ] MRCPass - Haematology

A 22 year old woman presents with
an acute pulmonary embolism in the 8th week
of pregnancy.

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What is the most appropriate treatment for
this patient throughout her pregnancy?

1- Clopidogrel

2- Intravenous heparin

3- Subcutaneous low molecular weight
heparin

4- Dipyridamole

5- Warfarin

Answer & Comments

Answer: 3- Subcutaneous low molecular
weight heparin

[ Q: 957 ] MRCPass - Haematology

A 80 year old woman presents with
generalised abdominal pains.

investigations show :

Hb 10.3g/dl WBC 17 x 10 9 /L

pits 80 x 10 9 /L MCV 85 fl

Blood film shows nucleated red cells, small
numbers of promyelocytes, myelocytes and
metamyelocytes

What is the most likely cause of these
haematology results?

1- Folate deficiency

Warfarin should only be used in the third
trimester. It is teratogenic and use in the first
2 trimesters are not recommended. At
present, the patient should have LMWH.

^ [ Q: 956 ] MRCPass - Haematology

#1 -

* A 45 year old woman has von

Willebrand's disease. She is going to undergo
tooth extraction.

Which one of the following is the best
management option in mild von Willebrand's
disease prior to surgery?

1- DDAVP

2- Factor VIII concentrate

2- Sickle cell disease

3- Osteoporosis

4- Thalassaemia minor

5- Myelofibrosis

Answer & Comments

Answer: 5- Myelofibrosis

Blood film findings describe a
leucoerythroblastic blood picture which is
characterized by granulocyte and erythroid
precursors in the peripheral blood. Common
causes include :

myelofibrosis

3- Fresh frozen plasma

4- Factor IX concentrate

5- Blood transfusion

bone marrow infiltration with leukaemia
severe megaloblastic anaemia
sickle cell crisis

Answer & Comments

Answer: 1- DDAVP

thalassaemia major
osteopetrosis

Out of all the choices, DDAVP is the most
pragmatic option. Fresh frozen plasma or von
Willebrand factor can be used in cases of
severe bleeding but should not be used in mild
cases.

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A leucoerythroblastic picture - presence of
immature myeloid and nucleated red cells in
the peripheral blood

[ Q: 958 ] MRCPass - Haematology

A 9 year old boy is unwell having
ingested a bottle of dye. On examination, he is
afebrile but has tachypnea, cyanosis, and
drow siness. He is given 100% oxygen but does
not improve.

Whot is the most likely diagnosis?

1- Methaemoglobinaemia

2- Sickle cell anaemia

3- Thalassemia

4- Congenital cyanotic heart disease

5- Henoch Schonlein purpura

Answer & Comments

Answer: 1- Methaemoglobinaemia

Cyanosis that is unresponsive to oxygen
therapy is most likely due to
methemoglobinemia.

Methaemoglobinaemia is a cause of cyanosis
because it causes the formation of reduced Hb
>1.5 g/dl. It is due to oxidised iron from Fe2+
to Fe3+ in Hb and may cause precipitation as
Heinz bodies.

Chemicals which are oxidising agents may
cause this e.g. aniline dyes, chlorates, nitrates,
nitrophenols, primaquine and sulphonamides.
Treatment is with methylene blue if
methaemoglobin >3.0g/dL.

[ Q: 959 ] MRCPass - Haematology

An 75 year old woman is admitted
for routine surgery. She is found to have a
haemoglobin of 7.8 g/dL with hypochromic,
microcytic indices and the blood film shows
pencil cells.

Whot is the most appropriate management?

1- Transfuse blood

2- Continue with surgery

3- Send haematinics and treat with ferrous
sulphate

4- Send haematinics and treat with Vitamin Bn

5- Request a bone marrow examination to
exclude myelodysplasia

Answer & Comments

Answer: 3- Send haematinics and treat with
ferrous sulphate

Iron deficiency is a common cause of anaemia,
especially in the elderly. In this age group, it is
often due to poor dietary intake, although
OGD or colonoscopy may need to be done to
exclude Gl bleeding as a cause of blood loss.

^ [ Q: 960 ] MRCPass - Haematology

# A 12 year old boy presents with
breathlessness and cough. On examination he
is pale and jaundiced. His Hb is 5.5 g/dl and
peripheral smear shows 50% sickled cells with
<1% reticulocytes.

Which of the following is responsible for his
condition?

1- Salmonella Infection

2- Pneumococcal infection

3- H. Influenzae infection

4- Cytomegalovirus infection

5- Parvovirus infection

Answer & Comments

Answer: 5- Parvovirus infection

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The child has sickle cell anaemia with an
aplastic crisis. This is most commonly
precipitated by parvovirus B19. Salmonella
can cause osteomyelitis and H influenzae can
cause pneumonia in patients with sickle cell
disease.

[ Q: 961 ] MRCPass - Haematology

A 48 year old man being has
polyuria, polydipsia and impotence.

On examination, he has a palpable enlarged
liver.

white cell count 3.5 x 10 9 /L (4-11)
platelet count 275 x 10 9 /L (150 - 400)
total protein 85 g/L (61 - 76)
albumin 32 g/L (37 - 49)
urea 18 mmol/l (3-7)
creatinine 350 micromol/L (60 -110)
calcium 2.85 mmol/l (2.25-2.7)
plasma glucose 5.5 (3.0 - 6.0)
urine dipstick analysis protein + blood +
renal ultrasound normal sized kidneys

Investigations show:

Alanine aminotransferase 80 U/L (5-35)

Aspartate aminotransferase 92 U/L (1-31)

Albumin 36 g/l Fasting plasma glucose 7.4
(3.0-6.0)

Ferritin 800 ug/L (15-300)

Which one of the following investigations is
appropriate?

1- Liver ultrasound

2- Thrombophilia screen

3- Serum electrophoresis

4- HAM test

Which one of following is the next best
investigation?

1- Oral glucose tolerance test

2- Serum transferrin receptors

3- Liver biopsy

4- Transferrin saturation

5- Bone marrow biopsy

Answer & Comments

Answer: 4- Transferrin saturation

The diagnosis is haemochromatosis suggested
by high ferritin. The best test now is
transferrin saturation. If this is high, HFE gene
analysis should also be performed.

[ Q: 962 ] MRCPass - Haematology

A 65 year old woman presents with a
6 month history of back pain.

She also mentions polyuria and lethargy.

Investigations reveal:

haemoglobin 9.2 g/dL (11.5 -16.5)

5- Thrombin time

Answer & Comments

Answer: 3- Serum electrophoresis

Anaemia, bone pain and hypercalcaemia are
typical presenting features of multiple
myeloma. Serum electrophoresis will show a
monoclonal band of either IgG, IgM or IgA
variety. Bence Jones protein may also be
found in the urine. About 15% of patients
have BJ protein in their urine without a
paraproteinaemia.

Plasma cells in multiple myeloma

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[ Q: 963 ] MRCPass - Haematology

A 13 year old female with known
sickle cell anaemia has been unwell with
fevers, anorexia and severe pains in the
muscles and joints of her upper and low er
limbs.

Her blood tests show :

Hb 4 g/dl
WCC 3.9 x 10 9 /L
Pit 75 x 10 9 /L

Absolute reticulocyte count 0.3(0.5-1.5)

LDH 280 (85-285) IU/L

Bilirubin 15 (1-22) pmol/l

Blood film reveals sickle cells with absence of
polychromasia.

What is the likely scenario?

1- Aplastic sickle crisis due to parvovirus

2- Acute haemolysis

3- Splenic sequestration

4- Sickle chest syndrome

5- Folate deficiency

Answer & Comments

Answer: 1- Aplastic sickle crisis due to
parvovirus

The most likely cause is aplastic crisis, the
commonest cause being parvovirus. The
reticulocyte count is low , bilirubin is normal
and LDH is normal.

Polychromasia is the presence of grey
coloured red cells on film, indicating presence
of increased reticulocytes.

The lack of polychromasia on the blood film
suggests aplastic anaemia.

Sickle Cell anaemia Aplastic Crisis. Numerous
sickled RBC's are present (small arrows)and A
single nucleated RBC is noted (large arrow ).
Note the absence of polychromasia.

[ Q: 964 ] MRCPass - Haematology

A 70 year old man is admitted for
investigation of jaundice and anorexia for
several weeks. 6 weeks ago, he had been
prescribed a two week course of Augmentin
by his GP for a severe upper respiratory tract
infection and was also taking Ibuprofen for
gout. He lives alone and has not had recent
travel. He drinks 2 units of alcohol a week.

Investigations reveal:

Albumin 40 g/L
Bilirubin 255 umol/L (1-22)

AST 260 iu/L (5-35)

Alkaline Phosphatase 220 iu/l (50-110)

Abdominal ultrasound reveals gallsones but
no evidence of cholecystitis.

What is the most likely cause of the jaundice?

1- Allopurinol

2- Augmentin

3- Alcoholic liver disease

4- Viral hepatitis

5- Ibuprofen

Answer & Comments

Answer: 2- Augmentin

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The blood results are consistent with
cholestatic jaundice. Co-amoxiclav
(augmentin) is a well known cause of this.
There is often a latency time betw een the use
of drug and onset of cholestatic jaundice.
Studies of case reports showed that the onset
of jaundice is typically from 2 weeks to 6
weeks for penicillins.

Some drugs cause a reaction even later -
several months. How ever, one should
scrutinise the data in your exam question
because the structure may be different.

[ Q: 965 ] MRCPass - Haematology

A 27 year old woman has routine
blood tests during her pregnancy.

Hb 9.8 g/dl

WBC 5.4 x 10 9 /L

Plts 260 x 10 9 /L

MCV 69 fl

MCH 17.2

What is the most likely diagnosis?

1- Folate deficiency

2- Beta thalassemia trait

3- B12 deficiency

4- Sideroblastic anaemia

5- Anaemia of chronic disease

Answer & Comments

Answer: 2- Beta thalassemia trait

Iron deficiency anaemia and thalassemia trait
are the two most likely diagnoses of
microcytic anaemia. Iron deficiency is best
diagnosed by a low ferritin level. Beta
thalassemia trait is diagnosed by the presence
of a raised HbA2 (with Hb electrophoresis).

^ [ Q: 966 ] MRCPass - Haematology

A 42 year old woman with a long
history of drinking alcohol has epilepsy. She

has been on phenytoin and carbamazepine
since the diagnosis was made 5 years ago.
Investigations reveal:

Haemoglobin 9.5 g/dL (13-16)

MCV 118 fL (80-96)

white cell count 2.5 x 10 9 /l_ (4-11)

platelet count 72 x 10 9 /l_ (150-400)

What is the most likely explanation for these
results?

1- Myelodysplasia

2- Aplastic anaemia

3- Folic acid deficiency

4- Side effect of carbamazepine

5- Chronic lymphocytic leukaemia

Answer & Comments

Answer: 3- Folic acid deficiency

Folic acid deficiency would fit the clinical
description and is a known adverse effect of
long term phenytoin therapy.

[ Q: 967 ] MRCPass - Haematology

A 40 year old lady who has been on
w arfarin for deep venous thrombosis
presents with upper Gl bleeding. Her INR was
9.1.

What is the appropriate treatment?

1- Protamine concentrate

2- Platelet transfusion

3- Cryoprecipitate

4- Factor VIII transfusion

5- Tranexemic acid

Answer & Comments

Answer: 3- Cryoprecipitate

Fresh frozen plasma and cryoprecipitate are
employed in treating patients with
coagulopathies due to deficiency of one or

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more coagulation factors. These conditions
may occur due to accelerated consumption of
coagulation factors, (e.g. bleeding, DIC),
impaired factor production states (vitamin K
deficiency, w arfarin effect, liver disease,
congenital factor deficiencies).

Cryoprecipitate contains fibrinogen, Factor
VIII, von Willebrand's Factor, Factor XIII, and
fibronectin.

[ Q: 968 ] MRCPass - Haematology
A 65 year old woman presents with

lethargy.

She has a Hb of 9.0 g/dl, WCC of 12 x 10 9 /l_,
platelets of 100 x 10 9 /dl, blood film shows
spherocytes, polychromasia and smear cells.
Direct Coomb's test is positive.

Which is the likely couse of the onoemio?

1- Thrombotic thrombocytopenic purpura

2- Autoimmune haemolytic anaemia

3- Idiopathic thrombocytopenic purpura

4- Hereditary spherocytosis

5- B12 deficiency

Answer & Comments

Answer: 2- Autoimmune haemolytic anaemia

The blood film and positive Coomb's test
points tow ards autoimmune haemolytic
anaemia. This may be related to a leukaemic
process in the patient with also raised WCC
and thrombocytopenia

[ Q: 969 ] MRCPass - Haematology

An 18 year old girl is being
investigated for w orsening menorrhagia and
gum bleeding. She undergoes a series of blood
tests which are shown below :

Hemoglobin 12.3 g/dl (10.5-13.5)
WBC 7.6 x 10 9 /L (6.0-17.5)
Platelets 328 x 10 9 /L (156-369)

APTT 52.6 s (28.0-38.0)

Bleeding Time 7 1/2 minutes (<5 minutes)
Prothombin Time 11.6 s (10.0-12.8)

Thrombin Time 17.3 s (16.0-22.0)

Factor VIII 0.18 U/ml (0.60-1.50)

Factor IX 0.92 U/ml (0.60-1.50)
vWFAg 0.16 s (0.78-1.53)

VWF ristocetin cofactor <0.10 U/ml(0.50-1.50)
Which of the following is the likely diagnosis?

1- Von Willebrand's disease

2- Factor V leiden

3- Carrier for Haemophilia A

4- Acute myeloid leukaemia

5- Idiopathic thrombocytopenia

Answer & Comments

Answer: 1- Von Willebrand's disease

She is most likely to have type 1 Von
Willebrand disease (vWD), w here the
prolongation of the APTT is due a low factor
VIII level which occurs secondary to the low
VWF level.

Von Willebrand disease (VWD) is a group of
genetically heterogenous disorders resulting
in abnormal function of the Von Willebrand
factor (VWF). More than 100 mutations have
been described. Symptoms include
mucocutaneous bleeding (epistaxis, easy
bruising, prolonged bleeding after minor
trauma, menorrhagia and gastrointestinal
bleeding) of varying severity. Hemarthrosis is
relatively uncommon. Unlike hemophilia, the
mode of inheritance is predominantly
autosomal dominant (some autosomal
recessive variants have been described).

Type 1 vWD is characterized by a partial
quantitative decrease of qualitatively normal
vWF and FVIII.

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Type 2A vWD is inherited is characterized by
normal-to-reduced plasma levels of factor
Vlllc (FVIIIc) and vWF.

Type 2B vWD is characterized by a reduction
in the proportion of high molecular weight
vWF multimers, while the proportion of low
molecular weight fragments are increased.

[ Q: 970 ] MRCPass - Haematology

A 5 year old boy was brought to the
emergency department by his mother for
oozing blood from his mouth following a fall.
His mother said that he tended to bleed for
prolonged periods from his immunization
sites, but there was no history of bruising or
hematomas. The patient was on antibiotics for
a recent ear infection. There was a family
history of similar bleeding - his sister and
mother being affected.

Blood tests show :

Hemoglobin 13.3 g/dl (10.5-13.5)

Hematocrit 35.4% (33.0-39.0)

WBC 6.9 x10 9 /L (6.0-17.5)

Platelets 350 x 10 9 /L (156-369)

PT 12.3 s (10.0-12.8)

APTT 38.2 s (24.4-33.2)

Bleeding time 12 minutes (2-9)

Whot is the diagnosis?

1- Haemophilia A

2- Haemophilia B

3- Von willebrand's disease

4- Acute lymphoblastic leukaemia

5- Acute myeloid leukaemia

Symptoms of von willebrand's disease include
mucocutaneous bleeding (epistaxis, easy
bruising, prolonged bleeding after minor
trauma, menorrhagia and gastrointestinal
bleeding) of varying severity. The quantitative
assay (VWF AG) and functional assay (VWF
ristocetin cofactor/ collagen binding capacity)
are recommended for diagnostic purposes.
Approximately 25% of patients with type 1
VWD have aPTT results outside of the
reference range.

DDAVP can raise the levels of vWF in the
blood.

Factor VIII concentrates and plasma products
can be used.

Using the ear lobe method, a normal bleeding
time is betw een 1 and 4 minutes. Using the
forearm method, a normal bleeding time is
betw een 2 and 9 minutes.

[ Q: 971 ] MRCPass - Haematology

A 75 year old lady has presented
with symptoms consistent with a UTI. Her
blood tests show Hb of 10.0 g/dl

WCC of 45 x 10 9 /L

platelets 160 x 10 9 /L

neutrophil count is 12 x 10 9 /L (1.5-7)

lymphocyte count is 27 x 10 9 (1.5-4)

Which of the following tests is the best to
elucidate a diagnosis?

1- Bone marrow trephine

2- White cell immunophenotyping

3- Hb electrophoresis

4- Ultrasound of abdomen

Answer & Comments

Answer: 3- Von willebrand's disease

In this case, the family history and also
prolonged bleeding time suggests von
Willebrand's disease. Von Willebrand's disease
has mostly autosomal dominant inheritance.

5- Splenic biopsy

Answer & Comments

Answer: 2- White cell immunophenotyping

A high white cell count with predominant
lymphocytosis and anaemia

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suggests a possible leukaemia such as Chronic
lymphocytic leukaemia. Immunophenotyping
can be used for classification of
undifferentiated leukemia as lymphoid or
myeloid and subclassification of leukemias.

[ Q: 972 ] MRCPass - Haematology

A 28 year old woman attends A+E
with a history of decreased consciousness. Her
investigations show :

Hb 6.7 g/dl

WBC 7.8 x 10 9 /L

pits 15 x 10 9 /L

APTT 34 secs

PT 16 secs

Fibrinogen 1.6 g/dl

Creatinine 180 pmol/l

Blood film: red cell fragmentation,
polychromasia and Burr cells.

What is the most likely diagnosis?

1- Multiple myeloma

2- Thrombotic thrombocytopenia purpura

3- Severe iron deficiency

4- Disseminated intravascular coagulation

5- Acute lymphoblastic leukaemia

Answer & Comments

Answer: 2- Thrombotic thrombocytopenia
purpura

Thrombotic thrombocytopenic purpura is a
syndrome characterized by microangiopathic
hemolytic anemia, thrombocytopenia,
neurologic abnormalities, fever, and renal
dysfunction. A spectrum of presentations
related to thrombotic events can occur,
altered consciousness, seizures, fever, myalgia
and arthralgia occur. With the introduction of
plasma exchange (recommended treatment),
the survival rate has improved from
approximately 3% prior to the 1960s to 82%.

The blood film in microangiopathic haemolytic
anaemia demonstrating
schistocytes(fragmented cells) and Burr cells.

[ Q: 973 ] MRCPass - Haematology

A 30 year old man presents with
painless lumps in the neck. This has been
present for the last 7 weeks. He has lost about
10 kgs in weight over the last six months and
complains of fever with night sw eats. He
smokes 20 cigarettes a day.

On examination there are several enlarged
lymph nodes in the left supraclavicular fossa.
Investigations are as follows:

Hb 10.3 g/dL

MCV 85 fl

WBC 16.0 x 10 9 /L

Neutrophils 55%
Lymphocytes 34 %
ESR 57 mm/hour

Which of the following tests would be most
appropriate to confirm the diagnosis?

1- Chest x ray

2- Kveim test

3- Sputum for AFB

4- Lymph node biopsy

5- Ultrasound scan of abdomen

Answer & Comments

Answer: 4- Lymph node biopsy

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The most likely diagnosis in a patient who has
cervical lymphadenopathy and B symptoms is
lymphoma.

[ Q: 974 ] MRCPass - Haematology

A 31 year old white woman has
recurrent episodes of epistaxis. Physical
examination revealed telangiectasias on her
forehead and buccal surface of the oral
mucosa.

Whot is the likely diagnosis?

1- Wegener's granulomatosis

2- Goodpasture's syndrome

3- Osier Rendu Weber syndrome

4- Haemophilia A

5- Von Willebrand's disease

Answer & Comments

Answer: 3- Osier Rendu Weber syndrome

The diagnosis is hereditary haemorrhagic
telangiectasia (Osier Rendu Weber syndrome).
Multiple telangiectasia are usually seen on the
hands and around the mouth. Arteriovenous
malformations are associated (pulmonary or
cranial).

[ Q: 975 ] MRCPass - Haematology

A 50 year old man has bronze
pigmentation. He has a family history of liver
problems. Clinical examination reveals
hepatomegaly. His investigations show :

Hb 14.0 g/dl

MCV 90 fl

MCHC 30 g/dl (32-35)

WCC 8 x 10 9 /L
platelets 180 x 10 9 /L
PT 17s (11.5-15.5)

APTT 35s (24-38)
urea 5 prnol/l

creatinine 80 pmol/l
sodium 140 mmol/l
potassium 3.6 mmol/l
bilirubin 26 pmol/l
AST 70 U/l
ALP 140 U/l
albumin 32 g/l
iron 50 ?mol/l (14-29)
ferritin 650 pg/l (15-200)
transferrin saturation 80%

Which of the following is the likely diagnosis?

1- Alcoholic liver disease

2- Haemochromatosis

3- Addison's disease

4- Chronic hepatitis C

5- Porphyria

Answer & Comments

Answer: 2- Haemochromatosis

There is high iron and ferritin. Transferrin
saturation of >50% is high. This is likely to be
haemochromatosis, which is autosomal
recessive. Venesection can help reduce ferritin
levels (aiming for 50 ?g/l).

[ Q: 976 ] MRCPass - Haematology

A 30 year old man has had 2
episodes of haemetemesis following
consumption of several pints of beer.

Investigations reveal: Hb 6 g/dl, WCC 1.7 x
10 9 /L, platelets 4 x 10 9 /L, PT 19s, APTT 52s,
fibrinogen 0.3 g/l (2-5), fibrin degradation
products 120ug/ml (<10).

Blood film reveals predominantly blast cells
containing Auer Rods.

Which of the following is the most likely
diagnosis?

1- Aplastic anaemia

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2- Disseminated intravascular coagulation

3- Immune thromobocytopenic purpura

4- Acute promyelocytic leukaemia

5- Acute lymphoblastic leukaemia

Answer & Comments

Answer: 4- Acute promyelocytic leukaemia

Acute myeloid leukaemia is defined as 20% or
more myeloblasts in the bone marrow . Acute
promyelocytic leukaemia (M3) is characterized
by presence of promyelocytes. There is an
association with the cytogenetic translocation
t(15:17).

Auer rods are elongated, bluish-red rods
composed of fused lysosomal granules, seen
in the cytoplasm of myeloblasts.

[ Q: 977 ] MRCPass - Haematology

A 62 year old woman had successful
knee surgery. A week following surgery, she
had a DVT despite prophylactic doses of low
molecular weight heparin.

Her blood tests showed: INR 1.1, APPT 37 s,
Fibrinogen 4.6 g/l, Hb 12.8 g/dl, platelets 18 x
10 9 /l_, WCC 22 x 10 9 /L Blood film showed
anisocytosis.

What is the likely diagnosis?

1- Idiopathic thrombocytopenic purpura

2- Disseminated intravascular coagulation

3- Thrombotic thrombocytopenic purpura

4- Heparin-induced thrombocytopenia and
thrombosis

5- Haemolytic uraemic syndrome

Answer & Comments

Answer: 4- Heparin-induced

thrombocytopenia and thrombosis

The timing of events, about 7 days after
commencing heparin suggests an immune-
mediated phenomenon. Despite

thrombocytopenia the patient is predisposed
to thrombosis. Platelet aggregation results in
thromboembolic events The normal
fibrinogen suggests DIC is unlikely.

[ Q: 978 ] MRCPass - Haematology

A 35 year old lady has had treatment
with penicillamine for rheumatoid arthritis.
She presents with weakness and pallor
claiming that it may be a side effect of the
drug.

Her Hb is 5 g/dl, WCC is 2 x 10 9 /I, platelet
count is 15 x 10 9 /L, INR is 1.0 and APTT is 27 s.

Which of the following is the most likely
diagnosis?

1- Acute myeloid leukaemia

2- Myelodysplasia

3- Aplastic anaemia

4- Folate deficiency

5- B12 deficiency

Answer & Comments

Answer: 3- Aplastic anaemia

There is pancytopenia due to bone marrow
failure. Aplastic anaemia can be congenital
(Fanconi's anaemia) or acquired due to drugs
(benzene compounds, insecticides, gold or
penicillamine).

Treatment is with antilymphocyte globulin,
cyclosporin or methylprednisolone.

[ Q: 979 ] MRCPass - Haematology

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An 8 year old boy is being investigated for
short stature.

Examination revealed 2 cafe au lait spots.
Blood tests showed: Hb 9 g/dl, WCC 2.5 x
10 9 /l_, platelets 28 x 10 9 /L.

What is the likely cause of anaemia?

1- Iron deficiency

2- Acute lymphoblastic leukaemia

3- Fanconi's anaemia

4- Folate deficiency

5- Multiple myeloma

Answer & Comments

Answer: 3- Fanconi's anaemia

Fanconi's anaemia often presents at age < 10
with growth retardation, renal defects and
cafe au lait spots. Inheritance is autosomal
recessive. 10% of patients may develop acute
myeloid leukaemia with time.

Answer & Comments

Answer: 3- Direct antiglobulin test

The direct antiglobulin test (DAT) is used to
detect IgG or C3 bound to the surface of the
red cell. In patients with hemolysis, the DAT is
useful in determining whether there is an
immune etiology.

Non-immune causes of hemolysis such as DIC,
thrombotic thrombocytopenic purpura,
mechanical hemolysis such as those due to
artificial valves or burns, hemoglobinopathies
(sickle cell, thalassemia), red cell enzyme
deficiencies (G6PDP, pyruvate kinase), and red
cell membrane defects (hereditary
spherocytosis, PNH) will have a negative DAT.

Immune causes of hemolysis including
autoimmune hemolytic anemias, drug induced
hemolysis, and delayed or acute hemolytic
transfusion reactions are characterized by a
positive DAT.

[ Q: 980 ] MRCPass - Haematology

A 35 year old woman presents with
jaundice and lethargy.

Her investigations reveal:

Haemoglobin 8.0 g/dL

reticulocyte count 150 x 10 9 /L (25-85)

serum bilirubin 75 umol/L

Her blood film reveals presence of
spherocytes

Which of the following is the next useful
investigation?

1- Endoscopy

2- Glucose 6phosphate dehydrogenase activity

3- Direct antiglobulin test

4- Red cell osmotic fragility

5- Haemoglobin electrophoresis

[ Q: 981 ] MRCPass - Haematology

A 40 year old man has had a bow el
operation. 48 hours later he becomes febrile,
hypotensive and unwell. His investigations
show :

Hb 12.6g/dl
WBC 17.4 x 10 9 /L
pits 45 x 10 9 /L

D-dimer 16,000 (<500) ng/dl
Fibrinogen 82 (180-363) mg/dl
Haptoglobin 6 (16-200) mg/dl
INR 2.4(1)

APTT 50 (<34)

What is the most likely cause of the
thrombocytopenia ?

1- Immune thrombocytopenia

2- Disseminated intravascular coagulation

3- Heparin induced thrombocytopenia

4- Thrombotic thrombocytopenic purpura

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5- Aplastic anaemia

Answer & Comments

Answer: 2- Disseminated intravascular

coagulation

Disseminated intravascular coagulation is
caused by inappropriate and excessive
activation of the haemostatic systems. 60%
are caused by Gram negative sepsis.

Other causes include viral infections,
metastatic carcinoma, leukaemia, obstetric
causes, extensive trauma and burns.

APTT, PT (INR) and TT are all prolonged,
platelets and fibrinogen are low , D-
dimers/FDPs are elevated. Other presenting
laboratory abnormalities include uremia,
elevated creatinine, elevated lactate
dehydrogenase, decreased haptoglobin,
bilirubinemia and lactic acidosis. Schistocytes
usually are evident on peripheral smear.
Treatment is of underlying causes and by
control of the haemorrhagic state. Platelets,
blood, cryoprecipitate and fresh frozen plasma
may all be required.

[ Q: 982 ] MRCPass - Haematology

A 30 year old man presents with
painless enlargement of his cervical lymph
nodes. He also complains of fever and night
sw eats. He has lost 1 stone in weight over the
past 3 months. Chest x ray shows mediastinal
widening.

A lymph node biopsy is performed and this
reveals a background of lymphocytes, plasma
cells, histiocytes, eosinophils, neutrophils and
fibroblasts. Scattered within this background
infiltrate are a number of large cells with two
large nuclei with prominent nucleoli.

The diagnosis is:

1- Tuberculosis

2- ALL

3- Hodgkin's lymphoma

4- Non Hodgkin's lymphoma

5- CLL

Answer & Comments

Answer: 3- Hodgkin's lymphoma

The clinical features are suggestive in
Hodgkin's disease and histology demonstrates
Reed-Sternberg cells, which are
pathognomonic. Reed-Sternberg cells are
characteristic bi-nucleate or multinucleate
cells found in Hodgkin's disease (ow Is eye
nuclei or church plate nuclei).

Staging is via the Modified Ann Arbor
classification:

I - Involvement of a single lymph node region
or a single extralymphatic site or organ.

II - Involvement of two or more lymph node
regions on the same side of the diaphragm (II)
or one or more lymph node regions plus an
extralymphatic site (ME).

III - Involvement of lymph nodes on both sides
of the diaphragm.

IV - Involvement of one or more
extralymphatic organs (Lung, liver, bone
marrow , with or without lymph node
involvement).

Chest x ray showing mediastinal widening due
to lymphadenopathy in Hodgkin's lymphoma

[ Q: 983 ] MRCPass - Haematology

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A 12 year old boy has recently been found to
be anaemic and is undergoing investigations.

He is short and has an abnormal facies with
frontal and parietal bossing, enlargement of
the malar (maxillary) bones and protruding
teeth.

On examination of the abdomen he has
hepatosplenomegaly. Investigations are as
follows: Hb 7.5 g/dl MCV 65 fl

Pit 160 x 10 9 /L

Which of the following is likely to treat the
anaemia?

1- Ascorbic acid

2- Ferrous sulphate

3- Vitamin B u

4- Folic acid

5- Blood transfusion

Answer & Comments

Answer: 4- Folic acid

The history of chronic anaemia and the
examination features suggest a chronic
haemolytic anaemia with extramedullary
erythropoiesis. This suggests the diagnosis of
thalassaemia. In thalassaemia, folic acid
supplementation is useful in treatment of
anaemia as there is increased metabolic
demand for folic acid.

[ Q: 984 ] MRCPass - Haematology

A 30 year old woman is bleeding a
lot after a thyroidectomy.

Investigations show:

Hb 11.3 g/dl

WBC 5.2 x 10 9 /L

Pits 230 x 10 9 /L

PT 15 sec (13-16 sec)

APTT 86 sec (28-38 sec)

APTT 50:50 mix with normal plasma 37 sec

Which of the following is the most likely
diagnosis?

1- Factor V deficiency

2- Anti-phospholipid syndrome

3- Factor VII deficiency

4- Factor XII deficiency

5- Von Willebrand's disease

Answer & Comments

Answer: 5- Von Willebrand's disease

An isolated prolonged APTT will be caused by
deficiencies in factors VIII, IX, XI and XII and by
von Willebrand's disease.

Anti-phospholipid syndrome can cause a
prolonged APTT but is not associated with
bleeding and the APTT is not corrected with
normal plasma. Factor X and V deficiency are
associated with both a prolonged PT and
APTT.

Factor VII deficiency is associated with a
prolonged PT.

[ Q: 985 ] MRCPass - Haematology

A 60 year old man presents with
back pains, abdominal pains and polyuria.

He has a Hb of 12 g/dl, WCC of 8 x 10 9 /L, pit of
300 x 10 9 /L.

Serum calcium is 2.9 (2.25-2.7) mmol/l and
phosphate 1.2 (0.8-8) mmol/l.

What might the bone marrow examination
show?

1- Increased blast cells

2- Increased proportion of plasma cells

3- Increased promyelocytes

4- Increased infiltration of lymphatic cells

5- Increased fibrosis

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Answer & Comments

Answer: 2- Increased proportion of plasma
cells

The diagnosis is multiple myeloma, and the
bone marrow shows increased amounts of
plasma cells (>30%) as seen in the image
below.

[ Q: 986 ] MRCPass - Haematology

A 55 year old man has acute onset
confusion, headache, nausea and vomiting
and visual disturbance. He had prescribed
been prescribed NSAIDS and antibiotics for
knee arthritis.

On examination he was overweight, he looked
plethoric, and cyanosed. There was 3
fingerbreadths hepatomegaly and the spleen
was enlarged about 5 fingerbreadths.

Investigations show :

Hb 21.2 g/dl MCV 71 fl

WBC 18 x 10 9 /L Na 135 mmol/I

K 3.8 mmol/l Urea 6.2 mmol/l

Creatinine 88 micromoles/l

Chloride 105 mmol/l

Bicarbonate 32 mmol/l

Calcium 2.5

Albumin 36 g/l

Phosphate 0.9 mmol/l

ESR 15 mm/lst hour

Whot is the best management?

1- Hyperbaric oxygen

2- Splenectomy

3- Prednisolone

4- Broad spectrum antibiotics

5- Venesection

Answer & Comments

Answer: 5- Venesection

The diagnosis is polycythaemia rubra vera.
Increased serum viscosity may arise from
hyperglobulinaemia or from an increased red
cell mass, polycythaemia. As a guideline,
erythrocytosis should be suspected in men
with a haemoglobin concentration greater
than 18.0 g /L or in w omen with values
greater than 17.0 g /L. Treatment of
hyperviscosity syndrome should be with fluid
replacement and venesection.

The cause of cyanosis is due to small vessel
insufficiency and thrombosis, which will
improve with venesection.

Hydroxyurea and anagrelide are
chemotherapeutic agents which can also be
considered.

[ Q: 987 ] MRCPass - Haematology

A 35 year old man has diabetes. On
examination he also has a slate grey
discolouration around his forearm. He has a
Hb of 13.5 g/dl, platelet count 350 x 10 9 /L, AST
of 35 U/l, ALP is 120 U/l, Albumin 35 g/l,
ferritin is 500 pg/l.

Which of the following tests is most helpful?

1- Copper and caeruloplasmin

2- Transferrin saturation

3- Fasting glucose

4- 72 hour fast

5- Short synacthen test

Answer & Comments

Answer: 2- Transferrin saturation

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The likely diagnosis is haemochromatosis due
to the diabetes, pigmentation, and raised
ferritin. Transferrin saturation would be raised
in haemochromatosis.

[ Q: 988 ] MRCPass - Haematology

A 72 year old woman presents with
malaise, headaches and weakness in her arms
and legs. Clinical examination reveals
lymphadenopathy and hepatosplenomegaly.
Nerve conduction tests show a sensory
neuropathy.

Her blood tests reveal Hb of 7.9g/dl, MCV 95
fl, WCC 9 x 10 9 /L. Her ESR is 80 and IgM
paraprotein of 18 g/l (0-5).

Which is the most likely diagnosis?

1- Multiple myeloma

2- CML

3- CLL

4- Waldenstrom's macroglobulinaemia

5- AML

Answer & Comments

Answer: 4- Waldenstrom's

macroglobulinaemia

In Waldenstrom's macroglobulinaemia,
increased serum proteins leads to a variety of
symptoms:

Neuropathy

Headache and focal nervous system
impairment

congestive cardiac failure.

Diagnosis is confirmed by high Ig M
paraprotein levels (also known as a spike).

A plasma cell on the blood film in
Waldenstrom's

^ [ Q: 989 ] MRCPass - Haematology

si -

# A 60 year old woman undergoes a
colostomy, which is complicated by a post¬
operative haemorrhage.

Following transfusion of 4 units of blood, her
haemoglobin is 12. g/dl.

A week later, she has the following results:

Hb 7.7 g/dl WBC 6.6 x 10 9 /L

Pits 377 x 10 9 /L MCV 96 fl

Bilirubin 66 umol/l

Direct Coombs test positive

Whot is the most likely diagnosis?

1- Further post-operative bleed

2- Subacute endocarditis

3- Delayed haemolytic transfusion reaction

4- Acute haemolytic transfusion reaction

5- Autoimmune haemolytic anaemia

Answer & Comments

Answer: 3- Delayed haemolytic transfusion
reaction

The most likely diagnosis is a delayed
haemolytic transfusion reaction. These are
due to incompatibilities in red cell antigens
other than the ABO groups. The antibodies are
acquired rather than naturally occurring so
they occur in patients who have been
pregnant in the past or who have had blood

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transfusions. When stimulated by transfusion,
antibody levels increase over 7-10 days to
cause a delayed haemolytic transfusion
reaction.

[ Q: 990 ] MRCPass - Haematology

A 65 year old lady presents with
malaise and weight loss, having been referred
by the GP for investigation of anaemia. His
investigations show :

Hb 8.0 g/dl

MCHC 33 g/dl (32-35)
platelets 130 x 10 9 /L
creatinine 90 pmol/l
potassium 4 mmol/I
AST 28 U/l

iron 50 ?mol/l (14-29)

ferritin 550 pg/l (15-200)

Bone marrow aspirate shows increased
haemosiderin, normoblastic hyperplasia and
ringed red blood cells

Which of the following is likely?

1- Acute myeloid leukaemia

2- Plasmacytoma

3- Chronic myeloid leukaemia

4- Sideroblastic anaemia

5- Chronic lymphoblastic leukaemia

MCV 105 fl
WCC 11 x 10 9 /L
urea 6 pmol/l
sodium 140 mmol/l
bilirubin 18 pmol/l
ALP 180 U/l

Ringed sideroblasts in a case of
myelodysplasia

[ Q: 991 ] MRCPass - Haematology

A 30 year old woman was sent to the
hospital for investigation following a upper
respiratory tract infection which was slow to
resolve. The following results were seen: Hb
11.5 g/dl, MCV 79 fl, platelets 650 x 10 9 /L,
WCC 10 x 10 9 /L, normal PT and APTT.

What is the likely couse of the
thrombocytosis?

1- Polycythaemia rubra vera

2- Sideroblastic anaemia

3- Reactive thrombocytosis

4- Myelodysplasia

5- Idiopathic thrombocytopenic purpura

Answer & Comments

Answer: 4- Sideroblastic anaemia

In sideroblastic anaemia, there is increased
bone marrow iron. This is reflected in the
increased iron stores in ferritin and also
haemosiderin and ringed premature red blood
cells (sideroblasts) due to excess iron.
Sideroblastic anaemia occurs due to an
enzyme deficiency (?ALA synthase 2
deficiency), alcohol, drugs (anti TB),
myelodysplasia.

Answer & Comments

Answer: 3- Reactive thrombocytosis

Reactive thrombocytosis may be due to
haemorrhage, iron deficiency, malignancy,
infection and connective tissue diseases.

[ Q: 992 ] MRCPass - Haematology

A 75 year old patient has been
unwell. Her blood tests show :

Hb 7.0 g/dl

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MCV110 fl
WCC 4 x 10 9 /L
platelets 70 x 10 9 /L
urea 5 pmol/l
creatinine 110 pmol/l
sodium 140 mmol/I
potassium 4 mmol/l

The blood film shows ring sideroblasts with
15% blast cells.

Bone marrow show hypercellularity
Which is the most likely diagnosis?

1- Acute myeloid leukaemia

2- Chronic myeloid leukaemia

3- Myelodysplastic syndrome

4- Chronic lymphatic leukaemia

5- Non hodgkin's lymphoma

Answer & Comments

Answer: 3- Myelodysplastic syndrome

Myelodysplastic syndromes are associated
with pancytopenias along with
dyserythropoietic ringed sideroblasts and
blast cells in the peripheral circulation.
Sideroblasts would be unlikely in AML and
CML, although blast cells could be seen. If the
bone marrow was hypocellular, then aplastic
anaemia would be possible in this question.

Bone Marrow biopsy in myelodysplasia
showing hypercellularity and abnormal
megakaryocytes

[ Q: 993 ] MRCPass - Haematology

A 45 year old intravenous drug user
is treated with unfractionated heparin for a
DVT as he is being assessed for endocarditis.
Two months previously, he had received
heparin. After 3 days of treatment, his platelet
count has fallen from a baseline of 180 x 10 9 /L
to 120 x 10 9 /L. Upon enquiry to the GP, he had
previously had blood tests which showed a
normal platelet count and he had no history of
bleeding problems.

Which of these statements is true?

1- Deep vein thrombosis

2- Type I HIT

3- Essential thrombocytopenia

4- Idiopathic thrombocytopenic purpura

5- Henoch Schonlein Purpura

Answer & Comments

Answer: 2- Type I HIT

The most likely diagnosis is heparin induced
thrombocytopenia, in view of the previous
normal platelet counts and recent use of
heparin. Although the patient becomes mildly
thrombocytopaenic, therapy can continue as it
is likely to remain mild. In Type II HIT,
antibodies would be more readily detectable
by ELISA and the thrombocytopenia would be
more severe.

[ Q: 994 ] MRCPass - Haematology

A 30 year old woman attends A&E
with marked breathlessness. Subsequently, a
pulmonary embolism is confirmed by V/Q
scan.

Blood tests reveal the following results:

PT 11/11s

APTT 67/31 s (50:50 mix test:normal plasma
55s)

TT 19/18 s
Hb 10.2 g/dl

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WCC 1.8 x 10 9 /L
Plats 90 x 10 9 /L

Which one of the following investigations is
most appropriate?

1- Antiphospholipid antibody

2- Bone marrow examination

Methaemoglobinaemia occurs when
haemoglobin is oxidised and is unable to carry
oxygen.

Drugs which can cause this condition include:

antibiotics (dapsone, sulphonamides and
trimethoprim)

3- Clotting factor levels

nitrites and nitrates

4- Testing for lupus anticoagulant

5- Thrombophilia screening

Answer & Comments

Answer: 1- Antiphospholipid antibody

The lupus anticoagulant is a form of
antiphospholipid antibody, and this is likely to
be present as there is prolonged APTT. The
name was given to the antibody because it
was first found in patients with lupus. The
presense of this is likely to have predisposed
the patient to a pulmonary embolus. Although
thrombophilia testing is indicated it is best left
until after the initial period of anticoagulation.

[ Q: 995 ] MRCPass - Haematology

A 35 year old woman was admitted
with breathlessness. On admission she looked
cyanotic and was given high flow oxygen
immediately. Arterial blood gas analysis
revealed a pH of 7.40, p0 2 of 11 kPa, pC0 2 of 4
and oxygen saturation of 50% by co-oximeter.

What treatment should be given?

1- N acetyl cysteine

2- Haemocdialysis

3- Methylene blue

4- Oral activated charcoal

5- Ascorbic acid

Answer & Comments

Answer: 3- Methylene blue

local anaesthetics (lignocaine and prilocaine).

Pulse oximeters measure both oxyHb and
metHb, therefore giving false reassurance in
patients with high levels of metHb. Methylene
blue is used in those with severe poisoning or
MetHb levels greater than 30%; excessive
doses of methylene blue can themselves
cause methaemoglobinaemia. Dapsone
poisoning can be treated by activated
charcoal, which adsorbs it.

[ Q: 996 ] MRCPass - Haematology

A 38 year old woman presents to the
hospital with a history of headaches,
decreased consciousness and fevers. Her
blood results show :

Hb 10.5 g/dl

WBC 14 x 10 9 /L

Pits 14 x 10 9 /L

Clotting screen normal

urea 15 pmol/l

creatinine 210 pmol/l

What is the most likely diagnosis?

1- Acute lymphoblastic leukaemia

2- Thrombotic thrombocytopenic purpura

3- Disseminated intravascular coagulation

4- Chronic myeloid leukaemia

5- Acute myeloid leukaemia

Answer & Comments

Answer: 2- Thrombotic thrombocytopenic
purpura

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The classic 5 features associated with TTP are:
fever

thrombocytopenia

microangiopathic haemolytic anaemia
renal failure
neurological symptoms

[ Q: 997 ] MRCPass - Haematology

A 35 year old man presents with a 10
day history of lethargy. He has a maculo-
papular rash and a 1 cm sized palpable
cervical lymph node. Investigations show :

Hb 13.6 g/dl

WBC 13.2 x 10 9 /L

Pits 280 x 10 9 /L

Blood film shows reactive lymphocytes
What is the most likely diagnosis?

1- Tuberculosis

2- SLE

3- Infectious mononucleosis

4- Acute myeloblastic leukaemia

5- Non-Hodgkin's disease

Answer & Comments

Answer: 3- Infectious mononucleosis

Common causes of a reactive lymphocytosis
include infectious mononucleosis (EBV
infection), CMV infection and toxoplasma
infection.

Reactive Lymphocytes

[ Q: 998 ] MRCPass - Haematology

A 40 year old man presents with
fatigue, weakness, and shortness of breath
with exertion over the past few days.

On examination, he is pale and jaundiced. His
heart rate is 110 and blood pressure is 110/65
mmHg. His breath sounds were clear, there is
a soft flow murmur audible in the aortic area.

Blood results show :

Hb 6.5 g/dl

MCV 105 fl

WCC 6.2 x 10 9 /L

platelets 250 x 10 9 /L

Reticulocyte count 14% (0.5% to 1.5%)

AST 27 (1-31) U/l

ALP 78 (20-120) U/l

Bilirubin 65 (1-22) pmol/l

lactate dehydrogenase 410 (105-333) U/L

The blood film shows spherocytes.

Which test should be performed next?

1- Direct Coomb's test

2- Osmotic fragility

3- HAM's test

4- Bone marrow aspirate

5- Haemoglobin electrophoresis

Answer & Comments

Answer: 1- Direct Coomb's test

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The diagnosis is autoimmune haemolytic
anaemia. In haemolytic anaemia, the bilirubin
and LDH are raised, there is a reticulocytosis,
and blood film shows spherocytes.
Autoimmune haemolytic anaemia is
associated with viral infections, drugs,
lymphoproliferative diseases and autoimmune
diseases.

The direct Coomb's test (DAT) is used to
detect IgG or C3 bound to the surface of the
red cell. In patients with hemolysis, the DAT is
useful in determining w hether there is an
immune etiology. Immune causes of
hemolysis, including autoimmune hemolytic
anemias, drug induced hemolysis, and delayed
or acute hemolytic transfusion reactions, are
characterized by a positive DAT. If the DAT
test is negative, then hereditary spherocytosis
should be considered.

Autoimmune haemolytic anaemia can be due
to warm or cold reacting antibodies,
depending on the cause of the autoimmune
reaction. Warm antibodies tend to be IgG and
lead to splenic destruction of red blood cells,
forming spherocytes. Cold antibodies are
usually IgM antibodies. They cause
intravascular haemolysis.

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roabti.rlw'j in a. tji- ri* 1 ?iiiL |'C o d mk 1 kffUJtiulBQ,

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Coomb's test

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^ [ Q: 999 ] MRCPass - Endocrinology

tl -

# A 22 year old student is diagnosed
with Grave's disease. She enquires about the
long term complications of radioactive iodine,
which is being considered.

What side effect is most likely?

1- Hyperthyroidism

2- Hypoparathyroidism

3- Hypothyroidism

4- Thyroid malignancy

5- Recurrent laryngeal nerve damage

4- Doxazosin

5- Bendrofluazide

Answer & Comments

Answer: 3- Spironolactone

The diagnosis is primary hyperaldosteronism
(Conn's syndrome). Spironolactone 200-400
mg is recommended as first line, but ACE-
inhibitors can also be used.

Surgical treatment (removal of an adenoma) is
definitive.

Answer & Comments

Answer: 3- Hypothyroidism

Radioactive iodine generally has few side
effects, is permanent, and very effective. It
cannot be used during pregnancy due to risks
of teratogenicity. It can often be performed as
an outpatient or with a short hospital stay.
The long-term risk is hypothyroidism, because
thyroid function is reduced so effectively that
thyroid replacement may be required.

[ Q: 1000 ] MRCPass - Endocrinology

A 40 year old man has a blood
pressure of 170/110 mmHg.

Laboratory findings include:

sodium 147 mmol/L (135-145)

potassium 2.6 mmol/L (3.5-5.0)

chloride 101 mmol/L (95-105)

glucose 5 mmol/L (3.5-5.5)

creatinine 90 umol/L (70-110)

His plasma renin activity is 0.15 ng/mL/hr and
his serum aldosterone 800 pmol/L (100-500).

Which drug is recommended for hypertension?

1- Ramipril

2- Atenolol

3- Spironolactone

[ Q: 1001 ] MRCPass - Endocrinology

A 22 year old man who has been
taking a drug has now developed hirsutism.

Which one of the following drugs is most likely
to be the couse?

1- Prednisolone

2- Minoxidil

3- Amphetamine

4- Propanolol

5- Acetylsalicylic acid

Answer & Comments

Answer: 2- Minoxidil

Causes of hirsutism include:

cyclosporin A

Risperidone

Minoxidil

Phenytoin

Ovarian tumours

Polycystic Ovary syndrome

Congenital adrenal hyperplasia

[ Q: 1002 ] MRCPass - Endocrinology
A 60 year old woman presents with

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anorexia, nausea vomiting and weight loss. On
examination she was dehydrated and looked
unwell.

Investigations reveal:

Hb 15 g/dl
WBC 5.7 x 10 9 /L
ESR40

Sodium 138 mmol/l
Potassium 3.7 mmol/l
Chloride 112 mmol/l
Bicarbonate 25 mmol/l
Urea 19.3 mmol/l
Creatinine 260 micromoles/l
Albumin 42 g/l
Calcium 3.3 mmol/l
Phosphate 0.60 mmol/l

Which of the following is the most likely
co use?

1- Vitamin D toxicity

2- Pseudopseudohypoparathyroidism

3- Congenital adrenal hyperplasia

4- Osteoporosis

5- Paget's disease

Which is the likely cytologic finding?

1- Squamous cell carcinoma

2- Small cell (oat cell) carcinoma

3- Large cell carcinoma

4- Adenocarcinoma

5- Teratoma

Answer & Comments

Answer: 2- Small cell (oat cell) carcinoma

The pigmentation and Cushingoid features are
typical features of ectopic ACTH secretion.
This is most commonly due to small cell
carcinoma, but may be associated with a
carcinoid tumour.

[ Q: 1004 ] MRCPass - Endocrinology

A 38 year old lady has fasting blood
glucose of 6.8 mmol/L.

Whot is the next investigation of choice?

1- Random glucose

2- C peptide level

3- Insulin level

4- Oral glucose tolerance test

5- Insulin tolerance test

Answer & Comments

Answer: 1- Vitamin D toxicity

This patient has probably been overtreated
with vitamin D. Severe hypercalcaemia (Serum
calcium > 3 mmol/l) may be associated with
malignant disease, hyperparathyroidism, renal
failure and vitamin D therapy.

^ [ Q: 1003 ] MRCPass - Endocrinology

# A 50 year old woman presents with
Cushingoid facies and hyperpigmentation of
the skin on her face. She smoked 20 cigarettes
per year for 20 years. Her chest X ray reveals a
3 cm mass in the right upper lobe. A CT guided
needle biopsy of the lung lesion is performed.

Answer & Comments

Answer: 4- Oral glucose tolerance test

In the oral glucose tolerance test the patient,
after fasting for 15 hours, drinks 75 g of
glucose in 300 ml of water, over 5 minutes.
Blood glucose is measured before the drink
and after 30, 60, 90 and 120 minutes. There is
a normal glucose tolerance if the venous
plasma value is less than 7 mmol/l after the 2
hour period. If after 2 hours after the glucose
load the value is betw een 7 and 11 mmol/l,
then there is impaired glucose tolerance. If
glucose is greater than or equal to 11.1
mmol/l, then there is diabetes mellitus.

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[ Q: 1005 ] MRCPass - Endocrinology

A 30 year old lady has recurrent
attacks of dizziness and blackouts. A 72 hour
fast reveals periods where her plasma glucose
is 2.5 mmol/I with elevated insulin and C
peptide levels.

Which is the next best investigation?

1- Repeat 72 hour fast

2- Glucagon stimulation test

3- Glucose tolerance test

4- MRI of abdomen

5- Insulin antibodies

Answer & Comments

Answer: 4- MRI of abdomen

The tests so far suggest an insulinoma.
Localisation of the insulinoma can be done
with MRI, CT, superior mesenteric
angiography or pancreatic venous
catheterisation.

Insulinoma

[ Q: 1006 ] MRCPass - Endocrinology

A 25 year old lady has mature onset
diabetes of the young (MODY). Her blood
sugars have been well controlled with
gliclazide 80mg bd. Her obstetrician refers her
to the physician for shared management of
diabetes.

Which is the best management step?

1- Increase gliclazide doses to 160 mg bd

2- Convert gliclazide to actrapid and insulatard
insulin injections

3- Convert gliclazide to metformin

4- Leave gliclazide doses unchanged

5- Stop gliclazide and monitor blood glucose

Answer & Comments

Answer: 2- Convert gliclazide to actrapid and
insulatard insulin injections

Gliclazide can cross the placenta and cause
fetal hypoglycaemia. In order to avoid
macrosomia and congenital disorders,
glycaemic control is best achieved with insulin
therapy during pregnancy. A tds actrapid
(short acting) regime with night insulatard
(long acting) will achieve best glycaemic
control.

[ Q: 1007 ] MRCPass - Endocrinology

A 45 year old man with type 2
diabetes attends the clinic. His HbAlc is
10.5%.

What average plasma glucose concentration is
this HbAlc value eguivalent to?

1- 7 mmol/I

2- 10 mmol/l

3- 12.5 mmol/l

4- 16 mmol/l

5- 20 mmol/l

Answer & Comments

Answer: 4-16 mmol/l

A HbAlc of 7% would translate into an
average glucose concentration of 9.5 mmol/l,
and a HbAlc of 10% into 15.5 mmol/l.

^ [ Q: 1008 ] MRCPass - Endocrinology

fL --"

# A 46 year old lady has been gaining
weight over the past year. She also has
features of hirsutism and abdominal striae.

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On examination, she was found to have
proximal myopathy.

Whot test should be done?

1- Short synacthen test

2- Random cortisol level

3- Low dose dexamethasone suppression test

4- Insulin tolerance test

5- Oral glucose tolerance test

Answer & Comments

Answer: 3- Low dose dexamethasone
suppression test

This lady is likely to have Cushing's syndrome.
A random cortisol is not that helpful - a 24
hour urine free cortisol collection should be
done, and also a low dose dexamethasone
suppression test (over 2 days) will confirm the
diagnosis if there is failure of cortisol
suppression.

[ Q: 1009 ] MRCPass - Endocrinology

A 55 year old woman with Cushing's
syndrome presents with left sided hip pain
acutely.

Which one of the following is most likely to
hove occurred?

1- Hip dislocation

2- Neuropathy

3- Necrosis of femoral head

4- Metaststic lesion

5- Iliac crest fracture

Answer & Comments

Answer: 3- Necrosis of femoral head

Cushing's Syndrome can present with necrosis
of femoral head due to osteoporosis. Necrosis
of the femoral head can also be caused by
avascular causes such as sickle cell disease,
diabetes, SLE and scleroderma.

Necrosis of the femoral head

[ Q: 1010 ] MRCPass - Endocrinology

A 22 year old man presents with
worsening lethargy over the past several
years. He also mentions long standing polyuria
and nausea.

Examination reveals that he has a BMI of 22
kg/m 2 and a blood pressure of 110/60 mmHg.

Examination of the cardiovascular and
abdominal systems are unremarkable.
Investigations reveal:

sodium 139 mmol/I

potassium 2.8 mmol/I

urea 6.6 mmol/I

creatinine 97 pmol/l.

ABGs showed pH of 7.5, normal pC> 2 ,
bicarbonate of 32 mmol/l (21 - 28).

Further investigation showed :

aldosterone 1195 pmol/l (111 - 863) -
ambulatory

renin 92 ng/ml/hr (7 - 76)

Whot is the likely diagnosis?

1- Type IV renal tubular acidosis

2- Conn's syndrome

3- Bartter's syndrome

4- Cushing's syndrome

5- Hypokalaemic periodic paralysis

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Answer & Comments

Answer: 3- Bartter's syndrome

Bartter's syndrome is an autosomal recessive
renal disorder. There is a Na-K-2CI
cotransporter gene defect.

Presentation is often in childhood with
gastrointestinal upset and polyuria. There is
associated hypokalaemic metabolic alkalosis,
elevated renin and aldosterone levels. High
urine chloride levels can be detected.
Vomiting, constipation, polyuria and
polydipsia are common symptoms.

Possible alternative diagnoses are diuretic
(thiazide) abuse or Gitelman's syndrome (the
difference is that Gitelman's syndrome causes
hypocalciuria and Bartters causes
hypercalciuria). Type 4 renal tubular acidosis
occurs in diseases associated with a failure of
aldosterone action or hypoaldosteronism.

[ Q: 1011 ] MRCPass - Endocrinology

A 55 year old man has
gynaecomastia.

Which one of the following drugs is most likely
to be responsible?

1- Ketoconazole

2- Morphine

3- Frusemide

4- Metoprolol

[ Q: 1012 ] MRCPass - Endocrinology

f -

# An 17 year lady presents with a 6
month history of secondary amenorrhoea. She
had previously been prescribed Temazepam
for anxiety. On examination, she had
galactorrhoea expression. Her prolactin
concentration was 4500 mu/I (50-450).
Pregnancy test was negative.

What is the likely diagnosis?

1- Acromegaly

2- Pituitary microadenoma

3- Polycystic ovarian syndrome

4- Drug induced hyperprolactinaemia

5- Turner's syndrome

Answer & Comments

Answer: 2- Pituitary microadenoma

The history examination findings together
grossly elevated prolactin concentration are
suggestive of a microprolactinoma. The most
frequent symptoms at onset are
oligoamenorrhoea (60%) and galactorrhoea
(50%), and headaches. Treatment is with
bromocriptine (e.g. 5 mg od).

[ Q: 1013 ] MRCPass - Endocrinology

A 30 year old lady has Polycystic
syndrome. She mentions difficulty
conceiving.

ovarian

5- Paracetamol

Answer & Comments

Answer: 1- Ketoconazole

Which one of the following drugs can help
improve fertility?

1- Metformin

2- Testosterone

Testosterone replacement therapy, Testicular
tumours, ACE inhibitors, calcium antagonists,
digoxin, cimetidine, ketoconazole,
metronidazole, tricyclic anti-depressants and
benzodiazepines may cause gynaecomastia.

3- Ethinyl oestradiol

4- Spironolactone

5- Cyproterone acetate

Answer & Comments

Answer: 1- Metformin

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Polycystic Ovarian Syndrome (PCOS) is
characterized by irregular ovulation and
menses, obesity, insulin resistance, acne, and
hirsutism (excessive hair growth). Impaired
fertility is a prominent feature of PCOS. This is
believed to result from elevated insulin levels
that stimulate excess androgen production by
the ovaries. The androgens cause premature
follicular wasting which causes inconsistent or
absent ovulation, which is associated with
infertility.

Metformin has been show n to increase rate
of conception in PCOS through improved
insulin sensitivity.

A polycystic ovary

[ Q: 1014 ] MRCPass - Endocrinology

A 25 year old lady has
oligomenorrhoea. As part of the hormone
screen, she has a prolactin level of 700 mU/l
(90-520).

Which one of the following is a couse of this
biochemicol picture?

1- Thyrotoxicosis

2- Chlorpromazine

3- Primary ovarian failure

4- Endometrial tumour

5- Post transsphenoidal surgery

Hyperprolactinaemia can be caused by drugs
(OCP or phenothiazines), hypothyroidism, liver
or renal failure, pituitary adenoma

/acromegaly.

[ Q: 1015 ] MRCPass - Endocrinology

A 53 year old man with insulin
dependent diabetes has routine follow up. On
examination, neovascularization w as found
on fundoscopy. Blood pressure was

146/92mm Hg.

Whot is the treatment of choice?

1- Better glycaemic control

2- Follow up after 3 months

3- Photocoagulation

4- Better blood pressure control

5- Statin

Answer & Comments

Answer: 3- Photocoagulation

Treatment is directed at regressing
neovascularisation using Argon laser pan-
retinal photocoagulation. The new vessels
themselves are not targeted but
photocoagulation is spread over a wide area in
order to destroy ischaemic retina and remove
the vasoproliferative stimulus. There is
variable visual loss and night blindness.

Photocoagulation scars following laser

treatment

Answer & Comments

[ Q: 1016 ] MRCPass - Endocrinology

Answer: 2- Chlorpromazine

A 60 year old man has had a

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thyroidectomy following a diagnosis of
follicular carcinoma. 2 days later, he develops
tingling sensations in his limbs and
neuromuscular irritability.

Which of the following is important?

1- Free T4

2- TSH

3- Triidothyronine

4- Corrected calcium

[ Q: 1018 ] MRCPass - Endocrinology

A 18 year old female with Addison's
has hydrocortisone treatment with a
dose of 20 mg in the morning and 10 mg in
the evening.

What dose of prednisolone would provide on
equivalent doily dose os her hydrocortisone?

1- 7.5 mg

2- 10 mg

disease

5- Magnesium

Answer & Comments

Answer: 4- Corrected calcium

The diagnosis is likely to be
hypoparathyroidism related hypocalcaemia.
Treatment is with intravenous calcium and
calcitriol supplementation. Tetany and carpo
pedal spasm may occur.

[ Q: 1017 ] MRCPass - Endocrinology

An 22 year old engineering student
presents with polyuria and polydipsia.

Which one of the following features will help
to confirm o diagnosis of diabetes mellitus?

1- 3+ ketonuria

2- A fasting plasma glucose of 7.5 mmol/L

3- A plasma glucose of 9.2 mmol/l 2 hours
after 75 grams of oral glucose.

4- An HbAlc of 6.5%

5- A random plasma glucose of >9 mmol/L

Answer & Comments

Answer: 2- A fasting plasma glucose of 7.5
mmol/L

3- 12.5 mg

4- 15 mg

5- 20 mg

Answer & Comments

Answer: 1- 7.5 mg

Equivalent dose strength of prednisolone:
hydrocortisone is 4 : 1. The total dose of
hydrocortisone is 30mg and prednisolone is
7.5mg.

[ Q: 1019 ] MRCPass - Endocrinology

A 75 year old man has a decreased
conscious level and is brought into hospital.
He has a blood glucose of 45 mmol/L and
sodium of 150 mmol/l. Urinalysis reveals no
ketones.

How should the patient be managed?

1- DIGAMI regime

2- Half normal saline and normal sliding scale
insulin

3- Half normal saline and reduced insulin
sliding scale

4- 10% dextrose infusion

5- 5% dextrose with insulin sliding scale

A random glucose of >11.1 and a fasting
glucose of >7.0 mmol/L would be regarded as
confirmatory. A raised glycosolated
haemoglobin (HbAlc) is also highly suggestive
but diagnostic.

Answer & Comments

Answer: 3- Half normal saline and reduced
insulin sliding scale

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The patient has hyperosmolar non ketotic
coma. When sodium is greater than 145
mmol/l, the patient should be given half
normal saline, and a sliding scale with low er
insulin doses (there is increased insulin
sensitivity).

[ Q: 1020 ] MRCPass - Endocrinology

A 70 year old man has who
presented with palpitations has runs of non
sustained ventricular tachycardia during
telemetry. Investigations show a serum
magnesium of 0.3 mmol/l (0.7-1.5).

Which one of the following is likely to have
caused this biochemical abnormality?

1- Elevated PTH level

2- Diuretics

3- Hyperphosphataemia

4- Chronic renal failure

5- Antacids

Answer & Comments

Answer: 2- Diuretics

3- Phaeochromocytoma

4- Hepatocellular carcinoma

5- Addison's disease

Answer & Comments

Answer: 5- Addison's disease

Addison's disease is described. Many
autoimmune diseases are associated e.g.
vitiligo, diabetes, primary ovarian failure and
pernicious anaemia.

[ Q: 1022 ] MRCPass - Endocrinology

A 45 year old man presents to his GP
complaining a disseminated, asymptomatic
papular eruption. Physical examination
revealed obesity with hundreds of pink to
yellow ish, soft papules located over the
buttocks, knees, elbows and neck.

He is found to have a triglyceride level of 5.2
(<1.69) mmol/l cholesterol 6.5 (<5.2) mmol/l.

Which one of the following is most likely to be
associated?

1- Nephrotic syndrome

Hypomagnesaemia may lead to life
threatening ventricular arrhythmias especially
in conjunction with hypokalaemia.

Posssible causes of hypomagnesaemia are:
Alcoholism, Drugs (Loop Diuretics,
Gentamicin, Cisplatin), Gastrointestinal
disorders (Vomiting, Diarrhoea,

Malabsorption), Renal loss, Hypercalcaemia,
Renal tubular acidosis.

[ Q: 1021 ] MRCPass - Endocrinology

fi -

# A 35 year old lady has skin
pigmentation, hypotension, hyponatraemia. A
short synacthen test shows a rise in cortisol
from 100 to 140 pg/ml.

What is the diagnosis?

1- Papillary thyroid carcinoma

2- Ovarian fibroids

2- Loop diuretic

3- Amyloidosis

4- Kartagener's syndrome

5- Hyperthyroidism

Answer & Comments

Answer: 1- Nephrotic syndrome

List of causes of raised triglycerides are

nephrotic syndrome

hypothyroidism

steroids

diabetes mellitus

renal failure

oral contraceptive pill

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glycogen storage disease (Von Gierke's)

This patient has eruptive xanthomas, have
also been reported in patients with acquired
forms of hypertriglyceridemia secondary to
uncontrolled diabetes mellitus, nephrotic
syndrome, alcohol and drug abuse.

In combination with elevated cholesterol,
nephrotic syndrome is a likely diagnosis.

Eruptive Xanthoma

[ Q: 1023 ] MRCPass - Endocrinology

An 70 year old lady is admitted with
loss of consciousness. She has a temperature
of 35 C, has a heart rate of 55, evidence of
cardiac failure, hypoventilation,

hypoglycaemia and hyponatraemia.

Which medication doses should be
administered?

1- Free T3 40 micrograms daily

2- Dexamethasone 8 mg orally daily

3- Hydrocortisone 100 mgs iv 8 hourly

4- Oral thyroxine 125 micrograms daily

5- Levothyroxine 2000 micrograms by slow
intravenous infusion every 8 hours

Answer & Comments

Answer: 3- Hydrocortisone 100 mgs iv 8 hourly

The patient has myxoedema coma.
Hydrocortisone 100 mgs iv 8 hourly should be
used to protect against the possibility of
associated adrenocortical deficiency. An initial
levothyroxine (T4) dose of 100 to 500 ?g
administered intravenously should be

followed by 75 to 100 ?g administered
intravenously daily until the patient is able to
take oral replacement.

[ Q: 1024 ] MRCPass - Endocrinology

A 52 year old man has been to her
GP a week ago for pharyngitis. He presents to
casualty feeling unwell with fevers and he has
diffuse, widespread areas of purpuric rash all
over his body.

Investigations show :

Sodium 125 mmol/L (135-145)

Potassium 5.2 mmol/L (3.5-5.0)

Chloride 91 mmol/L (95-105)

Glucose 2.6 mmol/L (3.0-5.5)

The most likely diagnosis is:

1- MEN 2

2- Waterhouse-Friderichson syndrome

3- Addison's disease

4- Sheehan's syndrome

5- Alkaptonuria

Answer & Comments

Answer: 2- Waterhouse-Friderichson

syndrome

Waterhouse-Friderichson syndrome is due to
meningococcal septicaemia resulting in
adrenal haemorrhagic insufficiency.

Symptoms and signs include hypotension,
abdominal pain, hyponatremia. The
progression is rapid. There may also be
disseminated intravascular coagulation in
patients with this syndrome. Mortality may
approach 100%.

The treatment is as that for meningococcal
infection, but with the addition of adrenal
support with hydrocortisone, given
intravenously in a dose of 200 mg per four
hours.

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Diffuse purpuric rash in Waterhouse-
Friderichson syndrome

[ Q: 1025 ] MRCPass - Endocrinology

A previously fit 36 year old man
presents with a 3 month history of weight
loss, pallor and lethargy.There is no

relevant past medical history and he does not
take regular medication. His blood pressure
was 103/56 mmHg with

a 20 mm Hg postural change measured. He
had unremarkable neurological and systemic
examination with a

normal computerised tomography and
magnetic resonance imaging of the brain.
Investigations show :

Haemoglobin 10.5 g/dL

serum sodium 128 mmol/L

serum potassium 6.2 mmol/L

serum urea 4.0 mmol/L

serum creatinine 85 umol/L

serum Total T4 60 nmol/L (50 - 150)

serum TSH 9 mU/L (0.2 -5.5)

Which of the following is the most useful
diagnostic investigation?

1- Anti-thyroid peroxidase antibody titre

2- Short synacthen test

3- Free T3 concentration

4- Glucose tolerance test

5- Growth hormone level

Answer & Comments

Answer: 2- Short synacthen test

Hyponatraemia and mild hypothyroidism
suggests that this patient might have
Addison's disease. The clinical history of
lethargy, weight loss and postural hypotension
also fits the diagnosis.

[ Q: 1026 ] MRCPass - Endocrinology

A 35 year old secretary has a blood
pressure of about 200/100 mmHg on several
occasions. She complains of polyuria, and
muscle weakness.

Investigations reveal:

sodium 146 mmol/L

potassium 2.4 mmol/L

Chloride 105 mmol/L

Bicarbonate 31 mmol/L

Urea 8.4 mmol/l

Which one of the following conditions is most
likely?

1- Medullary thyroid carcinoma

2- Pancreatic tumour

3- Adrenal adenoma

4- Adrenal hyperplasia

5- Hypoaldosteronism

Answer & Comments

Answer: 3- Adrenal adenoma

The features of high sodium and low
poatassium along with hypertension are
suggestive of primary hyperaldosteronism.
The most common cause of primary
hyperaldosteronism is unilateral adenoma
(Conn's syndrome ).

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An adrenal adenoma

[ Q: 1027 ] MRCPass - Endocrinology

A 22 year old girl is admitted with a

3-day history of rigors due to a urinary tract
infection. On examination, she has a
temperature of 39°C, looks unwell, has a body
mass index of 30 kg/m * 1 2 3 4 5 .

Initial investigations reveal:

Potassium 4.2 mmol/L (3.5-5)

Urea 6 mmol/L (2.5-7)

Glucose 30 mmol/L (3.0-6.0)

pH 7.4 (7.36-7.44)

Standard bicarbonate 12 mmol/l

Base deficit -12

Which one of the following is the best initial
treatment?

1- Metformin

2- Gliclazide

3- Acarbose

4- Sliding scale IV insulin infusion

5- Glargine insulin

breast-feed following delivery of a baby. Her
pregnancy was complicated by severe
intrapartum bleeding due to an undiagnosed
placenta praevia. She remains amenorrhoeic 3
months after delivery. She complains of
extreme lethargy.

Investigations show : sodium 129 mmol/l,
potassium 3.4 mmol/l, urea 5 pmol/l,
creatinine 90 pmol/l.

The diagnosis is likely to be:

1- Bilateral adrenal infarction

2- Normal pregnancy physiology

3- Prolactinoma

4- Multiple endocrine neoplasia

5- Pituitary apoplexy

Answer & Comments

Answer: 5- Pituitary apoplexy

The word apoplexy is defined as a sudden
neurologic impairment, usually due to a
vascular process. Pituitary apoplexy is
characterized by sudden onset of headache,
visual symptoms, altered mental status, and
hormonal dysfunction due to acute
hemorrhage or infarction of a pituitary gland.
The pituitary gland is susceptible to infarction
during pregnancy due to its increased
size/blood flow . Hyponatraemia,
hyperkalaemia and hypoglycaemia are as a
result of secondary adrenal failure due to lack
of ACTH.

Answer & Comments

Answer: 4- Sliding scale IV insulin infusion

The patient has mild acidodis and
hyperglycaemia, suggestive of diabetic
ketoacidosis, and hence should be on a sliding
scale insulin regime.

[ Q: 1028 ] MRCPass - Endocrinology
A 25 year old lady is unable to

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MRI showing a heterogenous pituitary mass in
the sella, which is non enhancing - Pituitary

Apoplexy

[ Q: 1029 ] MRCPass - Endocrinology

A 60 year old woman with a past
medical history of hypertension is assessed.
She has a 45 pack year smoking history. She
comes to the urgent care clinic today
complaining of a cough and shortness of
breath for the past w eek. Her physical exam is
notable for both mild wheezing and rhonchi,
more pronounced on the right side than the
left.

Lab results include the following:
Na 126 mmol/I
K 4.4 mmol/l
Creatinine 120 umol/l
Glucose 6 mmol/l
Urine osmolality is 400 mosm/kg
Plasma osmolality 285 mosm/kg
What is the diagnosis?

1- Renal salt wasting

2- Cranial diabetes insipidus

3- Nephrogenic diabetes insipidus

4- SIADH

5- Psychogenic polydipsia

Answer & Comments

Answer: 4- SIADH

SIADH is confirmed by inappropriately
elevated urine osmolality (often above 300
mOsm/kg) and urine sodium concentration
(usually above 20 mEq/liter). This case
scenario is consistent with a lung carcinoma.

* Hyponatremia with hypo-osmolality

* Elevated renal excretion of sodium (> 20 mEq/L)

* Normal volume status

* Inappropriately elevated urine osmolality for the plasma

osmolality

SIADH

[ Q: 1030 ] MRCPass - Endocrinology

A 40 year old patient has
investigation for Cushingoid features of
buffalo hump and central obesity. Serum
potassium is low at 2.5 mmol. Her ACTH value
is 200 pg/ml (5-50) and 24 hour urine cortisol
is grossly elevated.

Which one of the following is the most likely
diagnosis?

1- Adrenal carcinoma

2- Adrenal adenoma

3- Pituitary dependent Cushing's

4- Ectopic ACTH syndrome

5- ACTH overdose

Answer & Comments

Answer: 4- Ectopic ACTH syndrome

In ectopic ACTH syndrome, hypokalaemic
alkalosis is typical. Ectopic ACTH is not
suppressed by high doses of steroids such as 8
mg dexamethasome. Hypocalcaemia is not
caused.

Ectopic ACTH is typically caused by small cell
carcinoma of the lung. Thymoma, carcinoid
tumour, medullary carcinoma of the thyroid,
pancreatic carcinoma and

phaeochromocytoma are associated with
ectopic ACTH secretion. Squamous cell

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carcinoma is frequently associated with
hypercalcaemia.

[ Q: 1031 ] MRCPass - Endocrinology

/ -

# A 50 year old woman has weight

loss, palpitations and diarrhoea.

Examination reveals a single nodule on the left
lobe of the thyroid, measuring 3 cm in size.
Thyroid scintigraphy with Tc99 shows
increased uptake within this nodule.

Thyroid function tests showed a free thyroxine
of 29 pmol/L (9-25 pmol/L) and TSH <0.04
mU/L (0.5-5).

What is the best management?

1- Carbimazole

2- Propylthiouracil

3- Total thyroidectomy

4- Partial thyroidectomy

5- Radioactive iodine

Answer & Comments

Answer: 5- Radioactive iodine

The technetium scan suggests that the
thyrotoxicosis is due to a solitary toxic nodule.
Toxic thyroid nodules are best treated with
radioactive iodine.

[ Q: 1032 ] MRCPass - Endocrinology

A 44 year old man is investigated for
hypertension. His blood pressure is
consistently above 180/90 mmHg.

Blood results show :

pH 7.5

p0 2 -13 kPa

pC0 2 - 4 kPa

bicarbonate 32 (20-28) mmol/I
sodium 138 mmol/I
potassium 2.7 mmol/l
urea 6 pmol/l

creatinine 100 pmol/l
What is the likely diagnosis?

1- Essential hypertension

2- Conn's syndrome

3- Secondary hyperaldosteronism

4- Phaeochromocytoma

5- Congenital adrenal hyperplasia

Answer & Comments

Answer: 2- Conn's syndrome

Hypokalaemic alkalosis with refractory
hypertension suggests primary

hyperaldosteronism (Conn's syndrome).

Secondary hyperaldosteronism would also be
possible but tends to cause hypertension
which is easier to control.

Liddle's syndrome and Bartter's syndrome also
cause hypokalaemic alkalosis. If this case
scenario was a child with precocious puberty
then consider congenital adrenal hyperplasia.

[ Q: 1033 ] MRCPass - Endocrinology

A 35 year old lady has had no
periods for tw o years. She also notices
increased hair growth. Examination reveals
male pattern balding and hair grow th, and
clitoromegaly.

What is the likely diagnosis?

1- Cushing's disease

2- Adrenal tumour

3- MEN

4- Congenital adrenal hyperplasia

5- Ovarian tumour

Answer & Comments

Answer: 2- Adrenal tumour

An adrenal tumour is most likely, with
androgen secretion. Virilisation occurs. These

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are aggressive tumours and the treatment
option is surgery or radiotherapy.

MRI of a Large Right adrenal tumour

[ Q: 1034 ] MRCPass - Endocrinology

A 55 year old man presents with
generalised lethary, dizziness, headache,
visual disturbance, impotence and decreased
facial hair.

On examination he has a blood pressure of
110/70 with a postural drop.

On examination of his visual fields he is found
to have a bitemporal hemianopia. The
prolactin level is 4500 mlU/L.

An insulin tolerance test is performed and the
blood glucose levels falls to 1.3 mmol/L and
the patient becomes sweaty and tachycardic.

What is the diagnosis?

1- Medullary thyroid tumour

2- Addison's disease

3- Adrenal tumour

4- Phaeochromocytoma

5- Pituitary macroadenoma

This patient is likely to have an impaired
response to the insulin tolerance test as
prolactinoma may cause hyposecrestion of
other hormones. It is likely that the patient
has ACTH and cortisol deficiency as he has
features that are suggestive (tiredness,
dizziness, postural BP drop).

MRI showing a macroadenoma

[ Q: 1035 ] MRCPass - Endocrinology

A 60 year man has headaches and
visual impairment. He is suspected of having
acromegaly.

Which one of following is the best
investigation to confirm the diagnosis?

1- Insulin like growth factor 1 (IGF1)

2- Growth hormone releasing hormone test

3- 9 am growth hormone concentrations

4- Glucose tolerance test with growth
hormone concentration

5- Insulin tolerance test with growth hormone
concentrations

Answer & Comments

Answer: 5- Pituitary macroadenoma

The combination of headache, bitemporal
hemianopia and the prolactin level of > 3,600
mlU/L suggests the patient has a
macroadenoma.

Answer & Comments

Answer: 4- Glucose tolerance test with growth
hormone concentration

The diagnosis of acromegaly is confirmed by
inadequate suppression of Growth Hormone
concentrations below 2 mll/l in an oral
glucose tolerance test.

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[ Q: 1036 ] MRCPass - Endocrinology

A 45 year old woman has
palpitations, tremors, and episodes of anxiety
with associated sweating and confusion. There
is no history of diabetes. Blood insulin levels
are increased with increased C peptide levels
when measured during one of these episodes.

It is most likely due to:

1- Alcohol intoxication

2- Exogenous insulin

3- End stage renal disease

4- Insulinoma

5- Sepsis

Answer & Comments

Answer: 4- Insulinoma

Insulinoma caused high endogenous insulin
secretion and increased C peptide levels. This
would cause hypoglycaemia and symptoms
such as those listed above.

A raised aldosterone level and suppressed
renin levels suggest primary rather than
secondary hyperaldosteronism.

[ Q: 1038 ] MRCPass - Endocrinology

A 42 year woman presents with
episodic sw eats and tremors which are
relieved by sugary drinks. She gained
approximately 5 kg in weight in the past 3
months.

Her investigations show normal full blood
count, normal urea and electrolytes, and a
fasting plasma glucose concetration of 3.5
mmol/I.

Whot is the most appropriate investigation for
this patient?

1- Water deprevation test

2- 72 hour fast

3- Oral glucose tolerance test

4- CT scan of the head

5- Random Insulin C peptide concentration

[ Q: 1037 ] MRCPass - Endocrinology

A 35 year old lady was referred from
her GP for hypertension. Her plasma K is 2.8
mmol/L. Her BP was 210/130.

Fundoscopy revealed a bilateral papilloedema.
Investigations show : Supine Plasma
aldosterone 650 (100-450) Erect 30mins 620
pmol/L Supine Renin activity <0.2 (1.1-2.7),
Erect <0.2 (2.8-4.5).

The underlying diagnosis is:

1- Liddle's syndrome

2- Bartter's syndrome

3- Addison's disease

Answer & Comments

Answer: 2- 72 hour fast

The diagnosis is insulinoma. The standard
method of clinching the diagnosis during a 72
hour fast is by the demonstration of
inappropriately high insulin C peptide during
spontaneous hypoglycaemia.

Measurement of C peptide is also useful in
excluding factitious hypoglycaemia from self
injection of insulin. Insulin preparations do not
contain C peptide, hence if insulin levels were
high and C peptide levels were undetectable
then exogenous insulin abuse is likely.

4- Secondary hyperaldosteronism

5- Primary hyperaldosteronism

Answer & Comments

Answer: 5- Primary hyperaldosteronism

[ Q: 1039 ] MRCPass - Endocrinology

A 35 year old woman with
thyrotoxicosis is commenced on carbimazole.

Which one of the following is the first blood
test to improve?

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1- Thyroid stimulating hormone

2- Free T3

3- Total T4

4- Thyroglobulin

5- Total T3

Answer & Comments

Answer: 3- Total T4

Thyroxine (T4) is formed by coupling of
iodinated tyrosine residues within
thyroglobulin (TG).

Carbimazole acts by blocking the iodination of
tyrosine residues, hence reducing levels of T4.

[ Q: 1041 ] MRCPass - Endocrinology

* A 45 year old woman has undergone
investigations following routine blood tests
showing hypercalcaemia.

She has no symptoms. She has a calcium of 3.0
mmol/I (range 2.4-2.6 mmol/l), and 24-hour
urinary calcium excretion 25 mg (100-300).

What is the likely diagnosis?

1- Primary hyperparathyroidism

2- Secondary hyperparathyroidism

3- Multiple myeloma

4- Familial hypocalciuric hypercalcaemia

5- Widespread bony metastases

[ Q: 1040 ] MRCPass - Endocrinology

A 35 year old woman has had a
blood pressure of 180/105 mmHg for the past
month. She has also had headaches,
palpitations and sweaty episodes several
times a day. Urine adrenaline is 350 (<80)
nmol/l and noradrenaline is 2300 (<780)
nmol/l.

Which one of the following is the likely
diagnosis?

1- Renal artery stenosis

2- Conn's syndrome

3- Essential hypertension

4- Phaeochromocytoma

5- White coat syndrome

Answer & Comments

Answer: 4- Phaeochromocytoma

The diagnosis is phaeochromocytoma.
Although paraganglioma (10% of
phaeochromocytomas are extra-adrenal)
should be considered, it is associated with a
raised noradrenaline. Both raised adrenaline
and noradrenaline should make one suspect
adrenal phaeochromocytoma.

Answer & Comments

Answer: 4- Familial hypocalciuric

hypercalcaemia

The diagnosis here is familial hypocalciuric
hypercalcaemia.

Familial hypocalciuric hypercalcaemia is a rare
autosomal dominant disorder which has only
recently been recognised in which there is
reduced urinary calcium excretion in the
presence of hypercalcaemia.

Diagnosis is made on family history and
determination of low urinary calcium
clearance (this does not happen in
hyperparathyroidism).

Familial Hypocalciuric Hypercalcemia

Hypercalcemia with normal or low urinary
calcium

iPTH levels mav be elevated, but
hvpocalciuria is not dependent on PTH

Do not form calcium stones

Urinarv Ca/Creatinine clearance ratio of 01
*

or below helps distinguish from
liyperparathyroidism

[ Q: 1042 ] MRCPass - Endocrinology

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A 20 year old lady presents to casualty with
dizziness, lethargy, nausea and vomiting. On
examination, she has a BP of 95/50 mmHg and
generalised hyperpigmentation. Blood tests
showed: Na 129 mmol/l K 5.8 mmol/I, Urea
6.5 umol/l, Creat 110 umol/l.

The underlying diagnosis is likely to be:

1- Acute intermittent porphyria

2- Hypoparathyroidism

3- Hypothyroidism

4- Secondary adrenal insufficiency

5- Primary adrenal insufficiency

Answer & Comments

Answer: 5- Primary adrenal insufficiency

The clinical picture is consistent with an
addisonian picture. ACTH is produced in
primary adrenal insufficiency, hence causing
hyperpigmentation. This would not be
expected in secondary adrenal insufficiency.

pituitary. There may also be a gradual loss of
sexual function or libido.

[ Q: 1044 ] MRCPass - Endocrinology

A 60 year old man is found to have a
blood pressure of 185/110 mmHg. Serum
biochemistry showed normal electrolytes, and
normal renal function. An abdominal
ultrasound scan show s a 5-cm right adrenal
mass. Adrenal surgery is scheduled.

Which one of the following tests would hove
been most helpful prior to surgery?

1- Short synacthen test

2- 24 hour urinary cortisol

3- MRI scan of the abdomen

4- Renin and aldosterone levels

5- Urinary free catecholamines

Answer & Comments

Answer: 5- Urinary free catecholamines

[ Q: 1043 ] MRCPass - Endocrinology

Which one of the following is the
commonest presentation of o proloctinomo in
moles?

1- Galactorrhoea

2- Impotence

3- Gynaecomastia

4- Obesity

5- Depression

Answer & Comments

Answer: 2- Impotence

In men with prolactinoma the commonest of
the features mentioned above is impotence.

Because men have no reliable indicator such
as menstruation, many men delay seeking
medical advice until they have headaches or
visual problems caused by the enlarged

Urinary catecholamines would confirm a
diagnosis of a secretory phaeochromocytoma.
If so, the patient needs alpha blockade prior to
beta blockade, then surgery. MRI of the
abdomen or MIBG scan is also helpful
following biochemical confirmation of the
diagnosis.

[ Q: 1045 ] MRCPass - Endocrinology

A 60 year old woman who complains
tiredness. Her relatives mentioned depression
and has been on medication.

She has also been treated for cardiac failure
with diuretics. Her blood tests reveal a
corrected calcium 2.90 (2.2-2.7) mmol/l.

Which one of the following is most likely to
hove caused the raised calcium?

1- Frusemide

2- Paroxetine

3- Lisinopril

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4- Vitamin D deficiency

5- Lithium

4- Carbimazole

5- Radioiodine therapy

Answer & Comments

Answer: 5- Lithium

Answer & Comments

Answer: 4- Carbimazole

Drugs producing hypercalcemia include
lithium, alkaline antacids, DES, diuretics
(chronic administration of thiazides),
estrogens (incl. oral contraceptives), and
progesterone.

[ Q: 1046 ] MRCPass - Endocrinology

What dose of prednisolone is
equivalent in its glucocorticoid potency to 100
mg of hydrocortisone?

1- 5 mg

2- 25 mg

3- 50 mg

4- 75 mg

5- 100 mg

Answer & Comments

Answer: 2- 25 mg

Prednisolone is 4 x more potent than
hydrocortisone, and dexamethasone is
between 40 x more potent than
hydrocortisone.

[ Q: 1047 ] MRCPass - Endocrinology

A 60 year old man has been taking
amiodarone for paroxysmal atrial fbrillation.
He presents with lethargy and weight loss of
half a stone over 2 months. Investigations
reveal: Free T 4 35 pmol/L (10-22), TSH <0.01
mU/L (0.5-4.5).

How should this patient be treated?

1- Thyroxine

2- Thyroidectomy

3- Hydrocortisone

The appropriate initial treatment of
amiodarone induced hyperthyroidism would
be carbimazole.

Two types of amiodarone induced
hyperthyroidism are recognised. The first is a
consequence of iodine overload contained
within amiodarone of which the above is a
typical example. The second type is due to an
acute thyroiditis. This is best treated by
prednisolone.

[ Q: 1048 ] MRCPass - Endocrinology

A 42 year old lady presents with
malaise, thirst and increasing nocturia. The
symptoms have worsened over the last 2
months. She had an episode of renal colic
previously. Her GP had noted an eruptive,
painful, erythematous rash on her anterior
shins as well previously.

What is the likely metabolic abnormality?

1- Hypomagnesaemia

2- Hyperglycaemia

3- Hypercalcaemia

4- Hyponatraemia

5- Hyperoxaluria

Answer & Comments

Answer: 3- Hypercalcaemia

This lady has sarcoidosis. Hypercalcemia in
sarcoidosis is due to the uncontrolled
synthesis of 1,25-dihydroxyvitamin D3 by
macrophages. There is associated renal calculi
due to hypercalcaemia and also erythema
nodosum.

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[ Q: 1049 ] MRCPass - Endocrinology

A 55 year old patient with type 2
diabetes is reviewed in the diabetic clinic.

Which of the following is o feature of diobetic
neuropathy to watch out for?

1- Cervical myelopathy

2- Brisk reflexes

3- Muscle hypertrophy

4- Loss of vibration sense

5- Myotonia

Answer & Comments

Answer: 4- Loss of vibration sense

Autonomic neuropathy to the gut, bladder
and sexual organs (impotence) can occur. A
3rd nerve mononeuropathy can occur. Motor
neuropathy can cause muscle wasting, and
sensory neuropathy causes vibration sensory
loss. With myotonia, prolonged contraction of
muscle fibres associated with muscle
dystrophy is due to genetic causes of muscle
protein abnormality and is not neurologically
dependent.

[ Q: 1050 ] MRCPass - Endocrinology

A 40 year old patient who is diabetic
is concerned about having kidney problems in
the future. He has 1+ proteinuria on urine
dipstick.

Which of the following is most important in
order to preserve renal function?

1- Tight glycaemic control

2- Tight hypertension control

3- Going on to insulin

4- Regular renal ultrasound and 24 hour urine
check

5- Calcium replacement

Aggressive hypertension control is the best
way of preventing progression from
microalbuminuria to macroalbuminuria.
Although glycaemic control is important, it is
not as important as hypertensive control in
preventing progression tow ards nephropathy.

[ Q: 1051 ] MRCPass - Endocrinology

A 27-year-old female has been
diagnosed as having thyrotoxicosis and has
been started on carbimazole.

Which one of the following is a major side
effect of carbimazole?

1- Agranulocytosis

2- Thrombocytosis

3- Cholangiocarcinoma

4- Pityriasis rosea

5- Vascular thrombosis

Answer & Comments

Answer: 1- Agranulocytosis

Major side effects of carbimazole are:
agranulocytosis, thrombocytopaenia, acute
hepatic necrosis, cholestatic hepatitis, lupus¬
like syndrome and vasculitis.

[ Q: 1052 ] MRCPass - Endocrinology

A 40 year old man with hypertension

was also found to be significantly
hypokalemic.

Which of the following investigation is most
appropriate?

1- Renal arteriography

2- Ultrasound of the abdomen

3- Renin: Aldosterone Ratio

4- Plasma ACTH

5- Plasma cortisol level

Answer & Comments

Answer: 2- Tight hypertension control

Answer & Comments

Answer: 3- Renin: Aldosterone Ratio

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Conn's syndrome should be considered in a
patient who is not on diuretics who has the
following features:

hypertension, hypokalaemia and alkalosis.
Investigation of choice is plasma renin and
aldosterone - low renin and high aldosterone
(raised aldosterone: renin ratio) suggests
primary hyperaldosteronism.

2- Cyclical oestrogen and progestogen

3- Calcium and vitamin D supplements

4- Etidronate

5- Calcium supplements

Answer & Comments

Answer: 2- Cyclical oestrogen and progestogen

[ Q: 1053 ] MRCPass - Endocrinology

A 50 year old lady has a history of
breast cancer 5 years ago. She now has the
following investigation results:

calcium 2.9 (2.25-2.7) mmo

phosphate 0.75 (0.8-8) pmol/l
Parathyroid hormone 5.1 (0.8-8) pmo

Skeletal survey - generalised osteopenia
What is the diagnosis?

1- Primary hyperparathyroidism

2- Breast cancer metastasis

3- Multiple myeloma

4- Vitamin D overdose

5- Paget's disease

Answer & Comments

Answer: 2- Breast cancer metastasis

The high calcium and slightly low phosphate
would be consistent with high PTH, but the
PTH level is normal. Bone metastases can
cause PTH related peptide which would least
to hypercalcaemia.

As she is just recently post menopausal,
combined HRT treatment is the most
appropriate. At a later stage, calcium and
vitamin D supplements would be beneficial.
Etidronate is licensed for the prevention of
further osteoporotic fractures and as
prophylaxis against corticosteroid-induced
osteoporosis.

[ Q: 1055 ] MRCPass - Endocrinology

A 65 year old woman has had
increasing cold intolerance and weight gain.
Observations include sinus bradycardia,
depressed reflexes and a diffuse goitre.

Her serum TSH is 9 mll/L (0.5-4) with a free
thyroxine of 7.2 pmol/L (9-25 pmol/L). Anti¬
thyroid peroxidase antibodies and anti-
microsomal autoantibodies were detected at
high titres.

What is the diagnosis?

1- Hashimoto's thyroiditis

2- Previous carbimazole therapy

3- Pituitary tumour

4- Follicular thyroid carcinoma

5- De Quervain's thyroiditis

[ Q: 1054 ] MRCPass - Endocrinology

A 60 year old woman is assessed in
the rheumatology clinic for osteoporosis. She
is 1 and a half years post menopausal and has
a family history of osteoporosis.

What therapy should be commenced?

1- Vitamin D supplements

Answer & Comments

Answer: 1- Hashimoto's thyroiditis

The clinical picture is hypothyroidism. This is
likely to be due to primary autoimmune
hypothyroidism, also know n as Hashimoto's
thyroiditis. This disorder occurs most
commonly in middle-aged women and is

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caused by the reaction of the immune system
against the thyroid gland. It may occur in
people with a family history of thyroid
diseases or with other autoimmune diseases,
especially type 1 diabetes or adrenal
insufficiency.

De Quervain's thyroiditis (less likely diagnosis
in this case) is a subacute painful thyroiditis
and may result in hypothyroidism in the long
term.

[ Q: 1056 ] MRCPass - Endocrinology

A 60 year old woman has received
radioactive iodine over five years ago. She
now comes for her annual thyroid function
assessment. Her results reveal: Free Thyroxine
11 pmol/l (9.8-23), TSH 14 mU/l (0.5-4.5
mU/l), Total cholesterol 6.5 mmol/I (<5
mmol/l), Plasma triglycerides 2.1 mmol/I (<2
mmol/I).

Whot is the most appropriate treatment for
this patient's dyslipidaemia?

1- Hormone replacement therapy

2- Simvastatin

3- Thyroxine

4- Carbimazole

5- Fibrate

Answer & Comments

Answer: 3- Thyroxine

The patient has subclinical hypothyroidism as
reflected by a normal T4 but elevated TSH. A
hypercholesterolaemia or

hypertriglyceridaemia is frequently associated
due impaired lipoprotein lipase function.

Treatment should be with thyroxine
replacement first as the

hypercholesterolaemia should resolve.

[ Q: 1057 ] MRCPass - Endocrinology

/ -

* A 22 year old lady complains of

feeling lethargic for several months. She also
has generalized abdominal discomfort.

Investigations:

Hb 12.7 g/l

WBC 5.7 x 1071-

Platelet 290 x 107L

ESR 42 mm/hr

Na 133 (135-144) mmol/l

K 2.9 (3.4-4.5) mmol/l

Urea 6.0 (3-7) pmol/l

Creat 88 (50-100) pmol/l

Bicarbonate 36 (20-28) mmol/l

Alkaline phosphotase 95 (50-110) iu/l

bilirubin 15 (0-17)pmol/l

AST 35 (5-40) iu/l

Albumin 38 (33-44) g/l

What is the likely underlying diagnosis?

1- Pituitary tumour

2- Phaeochromocytoma

3- Acromegaly

4- Anorexia nervosa

5- Addisons disease

Answer & Comments

Answer: 4- Anorexia nervosa

Persistent vomiting with anorexia nervosa
would lead to dehydration, rebound
peripheral edema, low sodium, low
potassium, low chloride, metabolic alkalosis,
low magnesium, and low phosphate.

[ Q: 1058 ] MRCPass - Endocrinology

A 40 year old lady with a history of
end stage renal failure (on peritoneal dialysis)
and hypertension presented to the hospital

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with abdominal pain. She has been on
treatment with a vitamin D analog calcitriol.

calcium 2.88 (2.25-2.7) mmol/l

phosphate 0.9 (0.8-1.4) mmol/l

PTH level 314 pg/ml (10-60 pg/ml).

Which one of the following is the most likely
diagnosis?

1- Digeorge syndrome

2- Osteoporosis

3- Tertiary hyperparathyroidism

4- Waldenstrom's macroglobulinaemia

5- Osteomalacia

Answer & Comments

Answer: 3- Tertiary hyperparathyroidism

Secondary hyperparathyroidism occurs when
the parathyroid glands secrete increased
levels of PTH in response to low calcium; renal
failure is the most common cause of
secondary hyperparathyroidism.

If the causes of secondary
hyperparathyroidism persist, one parathyroid
gland may become autonomous; this gland
produces excess PTH even when calcium is
normal or elevated. This is known as tertiary
hyperparathyroidism.

Answer & Comments

Answer: 2- Hypertensive left ventricular failure

In acromegaly, cardiovascular disease is the
most important cause of mortality.
Hypertensive cardiomyopathy is a common
cause.

^ [ Q: 1060 ] MRCPass - Endocrinology

fi -

# A 36 year old woman with type I
diabetes complains of unsteadiness during
walking. Visual acuity is normal.

Fundoscopy shows preproliferative diabetic
retinopathy. There is loss of proprioception in
the toes and ankles bilaterally and a small
painless ulcer is noted under the right 1st
metatarsal head.

Which one of the following complications is
likely?

1- Diabetic retinopathy

2- Autonomic neuropathy

3- Peripheral neuropathy

4- Atherosclerosis

5- Diabetic ketoacidosis

Answer & Comments

Answer: 3- Peripheral neuropathy

^ [ Q: 1059 ] MRCPass - Endocrinology

# A 60 year old man with acromegaly
is enquiring about prognosis.

What is the most likely cause of mortality if
the condition is untreated?

1- Trauma from visual loss

2- Hypertensive left ventricular failure

3- Nephropathy

4- Colon carcinoma

5- Thyroid carcinoma

Peripheral sensory neuropathy in a glove and
stocking distribution is a frequent
complication of long-standing diabetes
mellitus. This causes loss of vibration, pain and
temperature sensation early on and later
proprioception may also be affected.

[ Q: 1061 ] MRCPass - Endocrinology

A 55 year old woman with Grave's
disease is being considered for radioiodine
treatment.

What is the most common effect of
radioiodine treatment?

1- Thyrotoxicosis

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2- Hypercalcaemia

3- Hypoglycaemia

4- Thyroid carcinoma

5- Hypothyroidism

Answer & Comments

Answer: 5- Hypothyroidism

Hypothyroidism is the commonest of these,
and may be transient in the early period, post
radioiodine. Hypothyroidism is the mosst
common complication. TSH should be
monitored 6 monthly after radioiodine.
Incidence of thyroid carcinoma is not
increased.

[ Q: 1062 ] MRCPass - Endocrinology

A 55 year old woman has
hypertension due to phaeochromocytoma.
She has attacks of hot flushes and
palpitations. Her 24-hour urinary
catecholamines show a markedly raised
noradrenaline.

How should she be treated?

1- Phenoxybenzamine only

2- Atenolol

3- Amlodipine and Propanolol

4- Phenoxybenzamine, Propanolol and then
surgery

5- Surgery without delay

Answer & Comments

Answer: 4- Phenoxybenzamine, Propanolol
and then surgery

Hypertension should be managed with
phenoxybenzamine initially, increasing up to
80 mg per day, with addition of propanolol
after 3-4 days of alpha blockade. Surgery
without adequate alpha and beta blockade
can result in hypertensive crisis (leading to
high CVA, Ml complications).

[ Q: 1063 ] MRCPass - Endocrinology

A 20 year old girl with an unusual
facial appearance is found to have coarctation
of the aorta. On examination, she had short
stature, a webbed neck and lymphedema.

Which is the likely diagnosis?

1- Patau's syndrome

2- Noonan's syndrome

3- Turner's syndrome

4- Down's Syndrome

5- William's syndrome

Answer & Comments

Answer: 3- Turner's syndrome

Turner's syndrome is typically associated with
coarctation of the aorta. They also have
features of webbed neck, cubitus valgus, short
fourth metacarpal, lymphoedema, low set
ears and hypertension.

Noonan's syndrome has a phenotype similar
to Turner's, and is associated with pulmonary
stenosis rather than coarctation.

[ Q: 1064 ] MRCPass - Endocrinology

A 50 year woman complains of
weight gain and menstrual irregularities. Her
BMI is 34 kg/m 2 , blood pressure is 165/90
mmHg. Urinalysis show s 2+ glucose.

Which investigation is likely to reveal the
diagnosis?

1- Renin and aldosterone

2- Fasting glucose

3- LH and FSH levels

4- 24 hour urine cortisol

5- Prolactin

Answer & Comments

Answer: 4- 24 hour urine cortisol

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Weight gain, high BMI, hypertension,
menstrual irregularities and glycosuria
suggests a diagnosis of Cushing's syndrome.
Investigations for this include the 24 hour
urine cortisol, dexamethasone suppression
test, ACTH levels and intra petrosal sinus
sampling.

[ Q: 1065 ] MRCPass - Endocrinology

A 25 year old man presents with
episodes of sw eating and tachycardia. He has
an enlarged adrenal gland on the left on the
CT of the abdomen.

In phoeochromocytomo, which of the
hormones is predominantly secreted by the
adrenal medulla?

[ Q: 1066 ] MRCPass - Endocrinology

An 18 yr old man has lethargy and
nausea. His plasma calcium is 2.72 mmol/L.
There is a family history of asymptomatic
hypercalcaemia in the siblings.

Investigations: PTH 70 pg/ml (<60), F E Ca
0.8% (fractional excretion of calcium).

The likely cause for this gentleman's
hypercalcaemia is:

1- Multiple myeloma

2- Primary hyperparathyroidism

3- Secondary hyperparathyroidism

4- Familial hypocalciuric hypercalcaemia

5- Vitamin D toxicity

1- Natriuretic peptide

2- Antidiuretic hormone

3- Cortisol

4- Adrenaline

5- Aldosterone

Answer & Comments

Answer: 4- Adrenaline

The diagnosis is phaeochromocytoma, which
is a tumour of the adrenal medulla. The
adrenal cortex produces aldosterone, cortisol
(glucocorticoid) and adrenal androgens. The
medulla produces adrenaline and
noradrenaline.

Phaeochromocytoma

Answer & Comments

Answer: 4- Familial hypocalciuric

hypercalcaemia

Familial hypocalciuric hypercalcaemia is an
autosomal dominant disease. The
pathophysiology is due to a defective calcium
receptor on the membranes of the
parathyroid and renal tubular cells. This
results in a decreased renal clearance of
calcium, PTH is usually normal or increased,
P04 is usually decreased. Typically, the
Fractional Excretion of Ca is <1%.

Familial Hypocalciuric Hypercalcemia

Hypercalcemia with normal or low urinary
calcium

iPTH levels mav be elevated, but

«#

hypocalciuria is not dependent on PTH

Do not form calcium stones

Urinary Ca Creatimne clearance ratio of .01
or below helps distinguish from
liyperparathyroidism

4 % [ Q: 1067 ] MRCPass - Endocrinology

A diagnosis of diabetes mellitus
being considered in 30 year old woman who is

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12 weeks pregnant. Her body mass index
(BMI) was 20 kg/m * 1 2 3 4 5 . A 75g oral glucose
tolerance test show s the following results:

Time Plasma glucose concentration

0 hour 5.5 mmol/l

2 hour 12.8 mmol/l

Which of the following is the appropriate next
step in the patient's management?

1- Gliclazide therapy

2- Subcutaneous insulin

3- Diet control

4- Metformin therapy

5- Repeat OGTT in four weeks

Answer & Comments

Answer: 3- Androgen insensitivity syndrome

Androgen insensitivity syndrome (AIS),
formerly known as testicular feminization, is
an X-linked recessive condition resulting in a
failure of normal masculinization of the
external genitalia in chromosomally male
individuals.

Most patients with complete androgen
insensitivity have a female gender. Some
patients are first seen in the teenage years for
evaluation of primary amenorrhea, but most
are identified in the new born period by the
presence of inguinal masses, which later are
identified as testes during surgery.

Answer & Comments

Answer: 2- Subcutaneous insulin

A pregnant lady with either gestational
diabetes or undetected diabetes should go on
to subcutaneous insulin to achieve good
glycaemic control in view of the potential
complications otherw ise.

[ Q: 1068 ] MRCPass - Endocrinology

A 16 year old female is evaluated in
the pediatric endocrinology clinic for primary
amenorrhea. Her family reported that she had
breast development at 11 years of age, but no
other pubertal changes. A testosterone level
was elevated at 3.08 ng/ml, and both pelvic
ultrasound and CT scan showed absence of
reproductive organs.

What is the likely diagnosis?

1- Anorexia nervosa

2- Early menopause

3- Androgen insensitivity syndrome

4- Klinefelters's syndrome

5- Turner's syndrome

[ Q: 1069 ] MRCPass - Endocrinology

A 45 year old woman presents with a
history of increasing tiredness. On
examination there is pigmentation of her skin
creases and buccal mucosa. Her blood
pressure is 85/50.

Investigations are as follows: Blood urea 8.2
mmol/l, Na 128 mmol/l, Potassium 6.2
mmol/l, Chloride 98 mmol/l, Bicarbonate 26
mmol/l.

What is the likely diagnosis?

1- Addison's disease

2- Porphyria

3- Hypoparathyroidism

4- Cushing's syndrome

5- Conn's syndrome

Answer & Comments

Answer: 1- Addison's disease

This patient has Addison's disease as
suggested by hyperpigmentation,

hyponatraemia and hypotension. A high 9 am
plasma ACTH level with low or normal cortisol
will confirm the diagnosis of primary
hypoadrenalism. A low cortisol response with

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the short ACTH (synacthen) test would also
show that the adrenal gland is not responding
to ACTH.

4- Primary hypothyroidisim

5- Secondary hypothyroidism

[ Q: 1070 ] MRCPass - Endocrinology

A 35 year old lady has recently been
commenced on a thiazide diuretic. She has
routine blood tests which reveal a sodium of
110 mmol/I, potassium 4.0 mmol/l, urea 6
pmol/l and creatinine 60 pmol/l.

Which of the following features is most likely
to occur?

1- Hypertension

2- Tachycardia

3- Decrease in conscious level

4- Elevated moods

5- Miosis

Answer & Comments

Answer: 3- Decrease in conscious level

Severe hyponatraemia can cause seizures,
obtundation/decreased conscious level,
headaches, upper motor neuron signs (central
pontine myelinolysis), bradycardia (not
tachycardia), hypotension and mydriasis.

[ Q: 1071 ] MRCPass - Endocrinology

A 35 year old woman has symptoms
of constipation, dry skin and low moods.
These symptoms have developed gradually
over the past several months.

Her TFTs show :

TSH 0.01 (0.3-4.0)mU/l

Free T 4 8.2 (10-24)pmol/l

low T3 of 2.1 pmol/L

What is the likely explanation?

1- Sick euthyroid syndrome

2- Grave's thyroiditis

3- Iodine deficiency

Answer & Comments

Answer: 5- Secondary hypothyroidism

Primary hypothyroidism is associated with
increased TSH and low T4 and T3. Secondary
hypothyroidism is due to pituitary failure,
resulting in low TSH, low T4 and T3.

Sick euthyroid syndrome can cause low T3 and
T4, but in this case unlikely because there is
no association with a critical illness.

[ Q: 1072 ] MRCPass - Endocrinology

A 50 year old man has recently had
an MRI scan to investigate for bitemporal
visual field loss. His pituitary gland is 15 mm in
diameter. A glucose load of lOOg orally fails to
suppress human growth hormone levels.

Which one of the following is the best
treatment?

1- Transphenoidal adenectomy

2- Pituitary radiotherapy

3- Bromocriptine

4- Octreotide

5- Pegvisomant

Answer & Comments

Answer: 1- Transphenoidal adenectomy

The best treatment option for a large pituitary
tumour in acromegaly is transphenoidal
removal of the tumour. Octreotide
(somatostatin analogue) and pegvisomant
(Growth hormone receptor blocker) are
effective forms of treatment. Bromocriptine
(dopamine agonist) is less effective.

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Pituitary tumour in acromegaly

[ Q: 1073 ] MRCPass - Endocrinology

A 55 year old woman has weight
loss, palpitations and diarrhoea. Examination
reveals a goitre with a single nodule on the
right lobe of the thyroid, about 3 cm in size.
Thyroid scintigraphy with Tc 99 shows
increased uptake within this nodule.

Thyroid function tests showed a free thyroxine
of 30 pmol/L (9-25 pmol/L) and TSH <0.08
mU/L (0.5-5).

What treatment should be recommended?

1- Carbimazole

2- Propylthiouracil

3- Thyroidectomy

4- Prednisolone

5- Radioactive iodine

[ Q: 1074 ] MRCPass - Endocrinology

—

A 50 year old man has progressive
deafness. He also complains of aching in the
legs and fatigue.

On examination, he has bowed legs and the
legs feel warm.

What is the most likely diagnosis?

1- Osteosarcoma

2- Osteoarthritis

3- Bony metastases

4- Paget's disease

5- Primary hyperparathyroidism

Answer & Comments

Answer: 4- Paget's disease

Paget's disease is characterized by excessive
breakdow n of bone tissue. The new bone is
structurally enlarged, but weakened and filled
with new blood vessels.

Frequently, bones of the pelvis, leg, spine,
arm, or the collar bone are involved. The
effect on the skull may enlarge head size and
cause hearing loss, if the cranial nerves are
damaged by the bone growth.

Fractures can occur. Other symptoms include
bone pain, bow ing of the legs, neck pains,
headaches and deafness.

Answer & Comments

Answer: 5- Radioactive iodine

The thyroid uptake scan confirms that this
lady's thyrotoxicosis is due to a solitary toxic
nodule. Toxic thyroid nodules are best treated
with radioactive iodine as this concentrates on
the overactive adenoma cells. Radioiodine
treatment is contraindicated in young
children, pregnant and lactating w omen.

Deafness may occur not just due to nerve
compression, but also secondary to pagetic
involvement of the bony ossicles.

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Bowed Tibia in Paget's disease

[ Q: 1075 ] MRCPass - Endocrinology

A 40 year old man presents with
chronic diarrhoea. He is suspected of having
the VIPOMA syndrome.

Which one of the following is a recognised
feature?

1- Weight gain

2- Metabolic alkalosis

3- Hypokalaemia

4- Hypoglycaemia

5- Increased gastric acid secretion

CT scan showing a VIPOMA

[ Q: 1076 ] MRCPass - Endocrinology

A 42 year old lady presents with
excessive weight gain, hirsutism and back
pain. Examination shows blood pressure
180/105, kyphosis and proximal myopathy. Of
note, her blood glucose is 9 mmol/l. A Dexa
scan shows a T-score -3.5 and a Z-score -2.5.

What is the diagnosis?

1- Multiple endocrine neoplasia

2- Multiple myeloma

3- Adrenal adenoma

4- Pheochromocytoma

5- Medullary thyroid carcinoma

Answer & Comments

Answer: 3- Hypokalaemia

Answer & Comments

Answer: 3- Adrenal adenoma

VIPOMAs secrete vasoactive intestinal peptide
(VIP) from a ganglioneuroma.

Features are:

The diagnosis is Cushing's syndrome due to
the clinical features of insulin resistance and
osteoporosis. Out of all the options, the best
fit as a cause is adrenal adenoma.

watery diarrhea

hypochlorhydria

hyperglycemia

hypercalcemia

flushing

[ Q: 1077 ] MRCPass - Endocrinology

A 45 year old man has type II
diabetes and is on oral medication. He
presents with vomiting and feels generally
unwell.

weight loss
metabolic acidosis

On examination, his BP is 110/70 mmHg. He
has a BM of 17.

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Investigations reveal: urea 21 mmol/I

creatinine 190 umol/l

HCO3- 14 mmol/l

lactate 6 (0.93-1.65) mmol/L

pH 7.22

Urine dipstick - ketone -ve

Whot is the likely couse of these findings?

1- Chronic renal failure

2- Metformin

3- Gastroparesis induced vomiting

4- Renal tubular acidosis

5- Diabetic ketoacidosis

Answer & Comments

Answer: 2- Metformin

3- NSAID related stomach ulcers

4- Multiple endocrine neoplasia

5- Tropical sprue

Answer & Comments

Answer: 4- Multiple endocrine neoplasia

The likely diagnosis is MEN la. Gastrinoma
may lead to duodenal ulceration and diarrhea.
Parathyroid adenomas may cause
hypercalcaemia. Infertility may be due to a
prolactinoma.

[ Q: 1079 ] MRCPass - Endocrinology

A 40 year old has been on intensive
care for 3 weeks following a difficult post
operative period, but now is rehabilitating
well.

The patient has features of metabolic acidosis
which is most likely to be due to lactic acidosis
caused by metformin.

[ Q: 1078 ] MRCPass - Endocrinology

A 41 year old woman presents with
significant abdominal pains and frequent
diarrhoea. She has been previously
investigated for infertility. Lansoprazole which
was prescribed by her doctor helped to relieve
her symptoms.

Investigations:

Haemoglobin 11.8 g/dl

Calcium 2.78 mmol/l

Albumin 41 g/l

Phosphate 0.75 mmol/l

CRP 11 mg/I

Endoscopy multiple duodenal ulcers

H. pylori negative

Whot is the likely diagnosis?

1- Ulcerative colitis

2- Coeliac disease

Her TFT's show : TSH 3.0 (0.3-4) mU/l, Free T 4
7.3 (8-24) pmol/l, T3 of 2.7 (3.3- 5.5) pmol/l.

Which diagnosis is the most likely
explanation?

1- Iodine deficiency

2- Sick euthyroid syndrome

3- Primary hypothyrodisim

4- Secondary hypothyroidis

5- Thyrotoxicosis

Answer & Comments

Answer: 2- Sick euthyroid syndrome

Sick euthyroid is seen in unwell patients who
are clinically euthyroid but have low levels of
T3 and T4. The syndrome is very common and,
in fact, may be found in up to 70% of
hospitalized patients. This is often why TFT's
are not accurate on patients in ITU. The
thyroid function tests should be repeated in a
few weeks' time.

[ Q: 1080 ] MRCPass - Endocrinology
A 70 year old man is found with a

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decreased conscious level. He has a blood
glucose of 40 mmol/L (3.5-5.0).

Urinalysis reveals no ketosis or proteinuria,
but there is 4+ glycosuria.

What is the diagnosis?

1- Insulinoma

2- Normal anion gap metabolic acidosis

3- Addison's disease

4- Hyperosmolar non ketotic coma

5- Diabetic ketoacidosis

Answer & Comments

Answer: 4- Hyperosmolar non ketotic coma

Hyperosmolar non ketotic coma is
characterised by markedly raised blood sugar,
often >50 mmol/L. There is no significant
ketosis and acidosis.

It occurs in patients with Type 2 diabetes of
middle age or older. Treatment should be with
isotonic saline , low dose insulin and
potassium replacement.

[ Q: 1081 ] MRCPass - Endocrinology

A 50 year old patient is being seen in
the ophthalmology clinic for pre-proliferative
retinopathy. He is a type II diabetic.

Which one of the following is most likely to
delay disease progression when treated?

1- Soft exudates

2- Hypertension

3- Glycaemic control

4- Hypercholesterolaemia

5- Stop smoking

Answer & Comments

Answer: 2- Hypertension

Diabetic retinopathy occurs in both type 1 and
type 2 diabetes. Progression may be slowed
by improving glycaemic and hypertensive

control, but hypertensive control has been
shown be more effective at reducing
progression (UKPDS). There are no data at
present suggest Statin therapy reduces
disease progression. Soft exudates are a
feature of preproliferative diabetic
retinopathy.

[ Q: 1082 ] MRCPass - Endocrinology

A 70 year woman with low bone
densitometry readings is currently taking
Raloxifene.

What form of drug is Raloxifene?

1- Selective estrogen receptor modulator
(SERM)

2- Anti interferon antibody

3- Corticosteroid

4- Hormone replacement therapy

5- Bisphosophonate

Answer & Comments

Answer 1- Selective estrogen receptor
modulator (SERM)

Selective estrogen receptor modulators
(SERMs) exhibit a pharmacologic profile
characterized by estrogen agonist activity in
some tissues with estrogen antagonist activity
in other tissues. The first widely used SERM,
tamoxifen, has estrogen antagonist activity in
breast tissue but shows estrogen-like activity
in other tissues. Raloxifene is another SERM in
clinical use, and it was developed to avoid
some of the undesirable estrogen agonist
actions of other SERMs to improve the drug
safety profile.

Raloxifene has been introduced for clinical use
in treatment and prevention of
postmenopausal osteoporosis.

[ Q: 1083 ] MRCPass - Endocrinology

L*lJ

A 65 year old woman has been

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prescribed thyroxine 150 ?g daily following a
diagnosis of hypothyroidism.

Having had replacement for several weeks,
her investigations revealed:

serum total T4 concentration 65 nmol/L (55 -
145)

serum total T3 concentration 0.7 nmol/L (0.9 -
2.5)

serum TSH concentration 15 mll/L (0.5 - 4)
Whot should be done?

1- Thyroid uptake scan

2- No action as it will resolve

3- Measurement of free T4 levels

4- Check anti thyroid antibodies

5- Enquire about compliance

Answer & Comments

Answer: 5- Enquire about compliance

Non compliance would explain the thyroid
function tests. The patient may have taken
thyroxine prior to coming for investigation,
hence a normal T4 but lowT3 concentration.

[ Q: 1084 ] MRCPass - Endocrinology

A 55 year old man presents with
lethargy and dizziness upon standing. He gives
a history of having had treatment for
tuberculosis when he was a child.

On examination he looks thin, his skin is
pigmented and there is pigmentation of his
buccal mucosa and pigmentation of the
palmar creases. There is no vitiligo. His blood
pressure is 120/80 lying and 85/60 on
standing.

His blood urea 8.4 mmol/L, Na 122 mmol/L, K
5.7 mmol/L.

Which of the following investigations is most
likely to identify the condition?

1- Short synacthen test

2- 0900 ACTH level

3- MRI pituitary

4- 24 hour urine catecholamines

5- Serum aldosterone /plasma renin activity

Answer & Comments

Answer: 1- Short synacthen test

The patient has Addison's disease,
predisposed to by previous adrenal
tuberculosis. The synacthen test is used to test
adrenal reserve. Synacthen is tetracosactrin,
the first 24 amino acids of ACTH.

The short synacthen test is done by:

1) take a basal sample for cortisol at time 0
min.

2) give 250 microgramme Synacthen i.v. or
i.m.

3) sample for cortisol are taken at 30 mins.
There should be a significant response unless
the patient is addisonian.

[ Q: 1085 ] MRCPass - Endocrinology

A 32 year old woman has been
treated for depression. She now complains of
thirst and drinking excessive amounts of
water. At the end of am 8 hour water
deprivation test, she has a serum osmolality of
290 mosmol/kg and urine osmolality of 100
mosmol/kg.

DDAVP (20ug intra-nasally) was given once
these results were seen, and her repeat urine
osmolality was 95 molsmol/kg.

Whot is the likely diagnosis?

1- Cranial diabetes insipidus

2- Nephrogenic diabetes insipidus

3- SIADH

4- Ectopic ACTH seretion

5- Psychogenic polydipsia

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Answer & Comments

Answer: 2- Nephrogenic diabetes insipidus

The clinical picture is possibly drug induced
(lithium) nephrogenic diabetes insipidus since
there is a history of depression. The plasma
osmolality normal range is 278-300
mosmol/kg and urine osmolality normal range
is 350-1000 mosmol/kg. Hence she has
inappropriately dilute urine despite water
deprivation.

At the end of the water deprivation, it is not
possible to tell whether it is cranial or
nephrogenic unless she is given a test dose of
DDAVP. If she starts concentrating the urine
(response to the synthetic ADH) then it is
likely to be cranial Dl. If she still does not
respond, as in this case, then it is likely to be
nephrogenic Dl.

^ [ Q: 1087 ] MRCPass - Endocrinology

f --—

# A 45 year old man has newly
diagnosed Conn's syndrome biochemically.

What is the most common cause of Conn's
syndrome in the UK?

1- Adrenocortical carcinoma

2- Adrenocortical adenoma

3- Phaeochromocytoma

4- MEN 1

5- MEN 2

Answer & Comments

Answer: 2- Adrenocortical adenoma

Conn's syndrome is most often caused by an
adrenocortical adenoma.

[ Q: 1086 ] MRCPass - Endocrinology

A 45 year old lady has recently been
diagnosed as a diabetic. Despite strict diet
control, her blood sugars are running at 12
mmol/l. She weighs 80kg.

Which of the following is the best medication
to start with?

1- Insulin

2- Glibenclamide

3- Metformin

4- Troglitazone

5- Gliclazide

Answer & Comments

Answer: 3- Metformin

[ Q: 1088 ] MRCPass - Endocrinology

A 32 year old patient with type 1
diabetes has now pregnant and is being
assessed in the diabetic clinic.

Which one of the following is the most
important?

1- Tight glycaemic control

2- Tight hypertensive control

Metformin is a biguanide. It improves insulin
sensitivity and is helpful especially in patients
who are overweight as it does not stimulate
appetites in the way that sulphonylureas do.

3- Manage only on oral hypoglycaemics

4- Anticoagulation with low molecular weight
heparin

5- Dipstick urine for ketonuria

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Answer & Comments

Answer: 1- Tight glycaemic control

Tight glycaemic control and close monitoring
with HbAlc is essential in view of
complications, including worsening diabetic
retinopathy. Many patients go on to insulin
rather than stay on oral hypoglycaemics.

^ [ Q: 1089 ] MRCPass - Endocrinology

# A 50 year old lady complains of
fevers, headache, tremor and palpitations. On
examination she has a BP of 220/110 mmHg, a
pulse rate of 120 and glycosuria. 24 hour
urinary vanillyl mandelic acid is measured at
85 micromoles/ 24h (normal 5-35
micromoles/24 h).

The hypertension should be treated with:

1- Clonidine

the past 3 months. Her BM was 23. Her ABG
showed a pH 7.28, HCO 16 mmol/I. Plasma
ketones are negative.

What is the likely diagnosis?

1- Diabetic ketoacidosis

2- Addison's disease

3- Hypothyroidism

4- Hyperparathyroidism

5- Hyper osmolar ketotic coma

Answer & Comments

Answer: 1- Diabetic ketoacidosis

Ketonuria may not be present at the early
stage of diabetic ketoacidosis. Some
laboratories can only detect a specific type of
ketone (acetoacetate) and the major ketone
present in DKA is betahydroxybutyrate.

2- Methyldopa

3- Propranolol before phenoxybenzamine

4- Phenoxybenzamine before propranolol

5- Bisoprolol

Answer & Comments

Answer: 4- Phenoxybenzamine before

propranolol

The diagnosis is phaeochromocytoma. The
treatment of hypertension in
phaeochromocytoma is with alpha blockade
prior to beta blockade. Alpha blockade
reverses the peripheral vasoconstriction
whereas beta blockade prevents tachycardia.
The preferred a-blocker phenoxybenzamine,
as is not a selective alpha 1 blocker but an
irreversible a-blocker whose effects cannot be
overcome by an increase of catecholamines.

[ Q: 1090 ] MRCPass - Endocrinology

A 15 year old girl presents to the
casualty with lethargy, malaise, polyuria and
polydipsia. She has lost 1 stone in weight over

[ Q: 1091 ] MRCPass - Endocrinology

A 25 year old patient has a father
who has previously been diagnosed with
medullary thyroid carcinoma,

hyperparathyroidism and

phaeochromocytoma. The patient has been
screened genetically and has the same gene
predisposing to the condition.

Which of the following is the most appropriate
management strategy?

1- Bilateral adrenalectomy and lifelong steroid
replacement

2- MRI of the brain

3- Thyroidectomy and regular 24 hour urine
for catecholamines

4- No further action unless symptomatic

5- Parathyroidectomy and bilateral
adrenalectomy

Answer & Comments

Answer: 3- Thyroidectomy and regular 24 hour
urine for catecholamines

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The condition is MEN 2. Since medullary
thyroid carcinoma is incurable, prophylactic
thyroidectomy is advised before disease
progression. How ever, bilateral
adrenalectomy is not necessary until there is
evidence for phaeochromocytoma
development.

[ Q: 1092 ] MRCPass - Endocrinology

A 45 year old woman has been
referred for investigation of abnormal liver
function tests. She drinks 40 units of alcohol a
week. On examination she is obese with
mainly truncal obesity, with a moon face and a
buffalo hump shaped deposit of fat across her
shoulders. Her face is plethoric and there are
numerous telangiectasia.

The abdomen is protuberant and there are
striae.

What is the likely diagnosis?

1- Adrenal adenoma

2- Pituitary dependent Cushings

3- Alcoholic pseudocushings

4- Ectopic ACTH secretion

5- Steroid use

Answer & Comments

Answer: 3- Alcoholic pseudocushings

The diagnosis is alcoholic pseudocushings, in
which ACTH, cortisol levels and dynamic
testing should not be abnormal.

[ Q: 1093 ] MRCPass - Endocrinology

A 18 year old man has poorly
developed secondary sexual characteristics.
He complains of a poor sense of smell. On
examination, he has little axillary or pubertal
hair, a small penis and testicular volumes of
approximately 4 ml bilaterally.

Investigations reveal:

Testosterone 3 nmol/L (10-30)

Prolactin 360 mll/L (<450)

FSH 2.5 iu/L (1-7)

LH 1.9 iu/L (1-10)

What is the most likely diagnosis?

1- 21 hydroxylase deficiency

2- 17 hydroxylase deficiency

3- Testicular feminisation syndrome

4- Kallman's syndrome

5- Adrenal adenoma

Answer & Comments

Answer: 4- Kallman's syndrome

Kallman's syndrome describes the occurrence
of hypothalamic gonadotrophin releasing
hormone deficiency and deficient olfactory
sense - hyposmia or anosmia. It is usually
inherited as an X-linked or autosomal
recessive disorder with greater penetrance in
the male. Nerve deafness, colour blindness,
mid-line cranio-facial deformities, and
cryptorchidism also occur.

[ Q: 1094 ] MRCPass - Endocrinology

# A 17 year old boy was seen at the
clinic for investigation of gynecomastia. On
examination, he was unusually tall, mildly
overw eight, he had gynecomastia and
hypoplastic testes.

What is the likely genetic karyotype?

1- 46 XO

2- 46 XY

3- 46 XX

4- 47 XYY

5- 47 XXY

Answer & Comments

Answer: 5- 47 XXY

This is the karyotype of Klinefelter's
syndrome.

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Boys with Klinefelter's syndrome often show
very discrete clinical features, including tall
stature, obesity, gynecomastia and eunuchoid
habitus, therefore the syndrome is often not
diagnosed. In addition, they have small testes,
a normal to low testosterone level and are
infertile.

[ Q: 1095 ] MRCPass - Endocrinology

A 20 year old lady with polycystic
ovary syndrome was prescribed Metformin.

How does metformin work in the condition?

1- Increasing oestradiol levels

2- Increasing follicle stimulating hormone
levels

3- Increasing gluconeogenesis

4- Increasing insulin levels

[ Q: 1096 ] MRCPass - Endocrinology

A 35 year old lady has complained of
syncopal episodes. She has had one previous
documented BM of 2.6.

Which of the following is the most appropriate
investigation?

1- 24 hour tape recording

2- Oral glucose tolerance test

3- Insulin tolerance test

4- 72 hour fast with insulin, C peptide and
plasma glucose sent when BM < 4

5- MRI of brain

Answer & Comments

Answer: 4- 72 hour fast with insulin, C peptide
and plasma glucose sent when BM < 4

5- Increasing peripheral glucose uptake

Answer & Comments

Answer: 5- Increasing peripheral glucose
uptake

Within the context of PCOS, metformin
decreases hyperinsulinism and increases
peripheral glucose uptake, reduces plasma
levels of luteinizing hormone (LH), and
reduces ovarian androgen production.

The diagnosis is likely to be an insulinoma.
Hypoglycaemic attacks are likely to be
witnessed during a 72 hour fast. Insulin and C
peptide levels are high, whilst glucose is low .
Sulphonylurea levels are also sent in cases
where oral hypoglycaemic drug misuse is
suspected.

^ [ Q: 1097 ] MRCPass - Endocrinology

n -

A 35 year old woman had no
menstrual periods for the past 6 months. She
is not pregnant and has not been on any
medication. Within the past week, she has
noted milk production from her breasts. She
has also had headaches for several months.

Which of the following laboratory test findings
is most likely to be present?

1- High prolactin level

2- Hypocalcaemia

3- High serum cortisol

4- Low serum growth hormone

5- High free thyroxine

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Answer & Comments

Answer: 1- High prolactin level

The headache and visual disturbance suggests
a macroadenoma. This could be prolactinoma
or acromegaly. The presence of galactorrhoea
and menstrual disturbance suggests high
prolactin levels. Levels of prolactin >3000
rnLI/L would be expected in
macroprolactinoma, and levels above 6000
rnLI/L are diagnostic. Prolactinomas are the
commonest functioning pituitary tumours.

[ Q: 1098 ] MRCPass - Endocrinology

A 25 year old man is investigated for
cryptorchidism. He has a cleft palate and
colour blindness. He is of normal stature. LH is
0.2 mlU/ml(2-18) and FSH is 1.2 mlU/ml(2-18).

Which one of the following is the likely
diagnosis?

1- Testicular feminisation syndrome

2- Kallmann's syndrome

3- Marfan's syndrome

4- Klinefelter's syndrome

5- Congenital adrenal hyperplasia 17
progesterone form

normal or above average stature. Females
may present with primary amenorrhoea;
males with cryptorchidism. LH and FSH levels
are typically low.

[ Q: 1099 ] MRCPass - Endocrinology

A 45 year old woman has a 2 year
history of treated hypothyroidism. There was
a short history of weight loss.

On examination she had a temperature of
37.7 C, a blood pressure of 85/35 mmHg. She
also had vitiligo.

Which one of the following should be given
intravenously initially?

1- Cefuroxime

2- 10% dextrose infusion and insulin

Answer & Comments

Answer: 2- Kallmann's syndrome

Kallman's syndrome describes the occurrence
of hypothalamic gonadotrophin releasing
hormone deficiency and deficient olfactory
sense - anosmia. It is usually inherited as an X-
linked or autosomal recessive disorder with
greater penetrance in the male.
Gonadotrophin deficiency arises from a failure
of embryonic migration of GnRH secreting
neurons from their site of origin in the nose.

More than half of patients have associated
nerve deafness, colour blindness, mid-line
cranio-facial deformities such as cleft palate or
harelip, and renal abnormalities. Most are of

3- T3

4- Fludrocortisone

5- Hydrocortisone

Answer & Comments

Answer: 5- Hydrocortisone

The diagnosis is Addison's disease. Many of
the presenting signs and symptoms are
nonspecific. Patients with mineralocorticoid
insufficiency may show signs of sodium and
volume depletion (eg, orthostatic
hypotension, tachycardia). Hydrocortisone
100 mg or 200 mg IV should be given, and
continued as a QDS dose. Fluid replacement
with dextrose is also recommended. Following
that, fludrocortisone acetate

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(mineralocorticoid) 0.1 mg qds should also be
given.

[ Q: 1100 ] MRCPass - Endocrinology

f -

# A 70 year old man presents with
significant back pains and lethargy, and
associated polydipsia.

His investigations show :

Haemoglobin 10.7 g/dl

Urea 18.5 mmol/l

Creatinine 320 micromol/l

Calcium 3.46 mmol/l

Blood tests show :

Glucose 7.5 mmol/L (3.5 -6.5)

LH 2.8 U/L (0.7-6)

FSH 5.3 U/L (<6)

Prolactin 320 mU/L (<425)

Testosterone 13.2 nmol/L (10-35)

GH 7 mU/L (<10)

Cortisol random 523 nmol/L (250-700)

TSH 2.8 mU/L (0.3-6)

FT4 17.5 pmol/L (9.4 -25)

What is the most likely underlying diagnosis?

Albumin 32 g/l
Total protein 98 g/l

Thoracic spine X rays show collapse of T7-T8
vertebrae.

Which investigation is most likely to confirm
diagnosis?

1- Blood film

2- Ultrasound of the liver

3- Parathyroid hormone levels

4- Serum electrophoresis

5- Creatinine Clearance

Answer & Comments

Answer: 4- Serum electrophoresis

The diagnosis is multiple myeloma, which is
suggested by the hypercalcaemia (polydipsia
and polyuria), renal failure and pathological
thoracic vertebral fractures.

[ Q: 1101 ] MRCPass - Endocrinology

A 50 year old man presents with a 6
month history of severe headaches. He has a
history of hypertension and osteoarthrits. On
examination, he has coarse facial features
with a prominent jaw . Visual fields
demonstrate bi-temporal hemianopia. BP
145/105 mmHg and glycosuria.

1- Macroprolactinoma

2- Conn's syndrome

3- ACTH secreting tumour

4- Sheehan's syndrome

5- Acromegaly

Answer & Comments

Answer: 5- Acromegaly

The clinical picture is consistent with
acromegaly, there is impaired glucose
tolerance, hypertension and enlarged pituitary
causing bitemporal hemianopia.

Enlarged hands and coarse facial features in

Acromegaly

[ Q: 1102 ] MRCPass - Endocrinology

A 40 year old patient with Addison's
disease is intolerant of her hydrocortisone
treatment which she takes at a dose of 20mg
in the morning and lOmg in the evening.

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Which one of the following closes of
prednisolone would provide on equivalent
doily dose ?

1- 2 mg

2- 5 mg

3- 7.5 mg

4- 10 mg

5- 20 mg

Answer & Comments

Answer: 3- 7.5 mg

Total dose of hydrocortisone is 30mg. The
equivalent ratio of prednisolone:
hydrocortisone is 1:4. Hence 30/4 = 7.5 mg.
The ratio for dexamethasone: hydrocortisone
is 1:40.

[ Q: 1103 ] MRCPass - Endocrinology

A 45 year old woman complains of
parasthesiae in her hands following a
thyroidectomy. She has spasms in her hands.

Whot blood test is most useful in this
situation?

1- Thyroid function test

2- Magnesium

3- Calcium

lethargy and weight loss. This has gradually
occured over the last 6 months.

On examination, a small goitre is palpable.
There is no evidence of eye signs or pretibial
myxedema.

Investigations reveal :

Free T 4 of 21.1 (9.8-23) pmol/l

T3 of 5.3 (3.3-5.5) pmol/l

a TSH of 0.05 (0.1-5) mU/l

Thyroid autoantibody titres are all negative

A thyroid uptake scan show s patchy uptake

Whot is the diagnosis?

1- Sick euthyroid syndrome

2- Toxic nodule

3- Grave's disease

4- Hashimoto's thyroiditis

5- De Quervain's thyroiditis

Answer & Comments

Answer: 2- Toxic nodule

This patient has subclinical hyperthyroidism.
Grave's disease is unlikely due to negative
antithyroid antibodies. This is because the T4
and T3 levels are normal. How ever, the TSH is
reduced, so the hyperthyroidism is subclinical.

4- Potassium

5- Sodium

Answer & Comments

Answer: 3- Calcium

This patient has hypoparathyroidism post
thyroidectomy, leading to hypocalcaemia.
Treatment is with calcium and calcitriol
supplementation. Signs are tetany, carpal
spasm and Chvostek's sign.

[ Q: 1104 ] MRCPass - Endocrinology
A 65 year old man presents with

Toxic multinodular goiter or toxic nodule is
more common in the elderly. Very recently,
activating point mutations in the TSH
receptor, which result in continuous thyroid
stimulation, have been described in the
solitary nodule. It can cause hyperthyroidism
or subclinical hyperthyroidism.

In patients with multinodular goitre, the
thyroid uptake scan (with radioactive iodine)
usually reveal patchy uptake, with areas of
both increased and decreased uptake.
Patients with Graves disease usually have
homogeneous diffuse uptake. Glands with
thyroiditis have low uptake.

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Sick Euthyroid syndrome is usually associated
with critically ill patients. Hashimoto's and De
Quervain's thyroiditis are usually associated
with hypothyroidism.

[ Q: 1105 ] MRCPass - Endocrinology

A 35 year old type 1 Diabetic patient
presents to the clinic for review . Her urine
dipstick show s blood +, protein ++, leucocytes
-. HbAlc is 8.2.

Which drug, when commencedwill hove on
impact on mortality?

1- Insulin

2- Metformin

3- Lisinopril

4- Gliclazide

Answer & Comments

Answer: 1- Primary hyperparathyroidism

The disorder is relatively common disorder
amongst elderly females. In primary
hyperparathyroidism, typically there is
hypercalcaemia, low phosphate and raised
alkaline phosphatase. PTH acts directly on
kidney (glomerular Ca++ resorption) and bone
Ca++ resorption (rate of dissolution of bone
mineral) and indirectly on intestine via control
of vit D derivative l-alpha-25-(OH)2D
(calcitriol) synthesis in the kidney. Levels of
PTH are regulated by a classic feedback loop

Incidence of primary hyperparathyroidism is
1:800.

Causes include :

5- Bendrofluazide

Adenomas (single 80%)

Answer & Comments

Answer: 3- Lisinopril

Parathyroid hyperplasia
Parathyroid carcinomas (2-3% cases)

ACE inhibitors have been show n to be of
benefit in d nephropathy - with an improved
mortality outcome in the long term.

[ Q: 1106 ] MRCPass - Endocrinology

A 70 year lady has lethargy and is
investigated at the hospital. Her investigations
reveal:

[ Q: 1107 ] MRCPass - Endocrinology

A 55 year old man has large spade
like hands and finds that he is having to buy
shoes of increasing size. On examination of his
visual fields, bitemporal hemianopia was
found.

Which one of the following tests should be
done?

Corrected calcium 2.86 (2.2-2.6) mmol/I
Phosphate 0.80 (0.81-1.4) mmol/l
Alkaline phosphatase 120 U/L (20-95)

PTH concentration 5.8 pmol/L (0.9-5.4)

Whot is the likely diagnosis?

1- Primary hyperparathyroidism

2- Multiple myeloma

3- Osteoporosis

4- Paget's disease

5- Ectopic PTH related peptide (PTHrp)
secretion

1- Insulin tolerance test

2- Hydrocortisone curve

3- CT scan of the chest

4- Dexamethasone suppression test

5- Oral glucose tolerance test with growth
hormone

Answer & Comments

Answer: 5- Oral glucose tolerance test with
growth hormone

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Growth hormone suppression during oral
glucose tolerance and elevated IGF-I levels
form the main diagnostic criteria in
acromegaly. An MRI scan (to look for
macroadenoma) is also important.

[ Q: 1108 ] MRCPass - Endocrinology

A 8 year old boy is investigated for
short stature. He has short limbs, trunk and
and saddle shaped nose. X rays reveal
epiphyseal dysplasia.

Whot is the diagnosis?

1- Achondroplasia

2- Paget's disease

3- X linked hypophosphataemic rickets

4- Congenital adrenal hyperplasia

5- Congenital osteoporosis

Answer & Comments

Answer: 1- Achondroplasia

Achondroplasia is an autosomal dominant
condition which is one of commonest forms of
inherited dwarfism.

Epiphyseal dysplasia occurs and there is a
diminished columnar arrangement short thick
bones, spinal length almost alw ays normal.
Features include short limbs, trunk, large
head, saddle nose and exaggerated lumbar
lordosis.

Achondroplasia

[ Q: 1109 ] MRCPass - Endocrinology

A 45 year old man has a blood
pressure of 180/105 mmHg found by the GP
and was referred for further investigation.

Blood tests show :

serum sodium 144 mmol/L (135-145)

potassium 2.5 mmol/L (3.5-5.0)

chloride 102 mmol/L (95-105)

glucose 5.3 mmol/L (3.5-5.5)

creatinine 100 umol/L (70-110)

His plasma renin activity is 0.1 ng/mL/hr and
serum aldosterone is 680 pmol/L (100-500).

Which is the best drug to prescribe?

1- Atenolol

2- Lisinopril

3- Bendrofluazide

4- Spironolactone

5- Losartan

Answer & Comments

Answer: 4- Spironolactone

Primary hyperaldosteronism (Conn's
syndrome due to a single adenoma), responds

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w ell to Spironolactone 200-400 mg. ACE
inhibitor and angiotensin II antagonists can
also be used. The definitive treatment how
ever is surgery.

[ Q: 1110 ] MRCPass - Endocrinology

A 22 year old girl complains of
feeling tired for the last 6 months. She also
has generalized abdominal discomfort and
poor bow el movement. Examination show s a
pale and thin young woman. Her blood
pressure is 110/60 mmHg.

Investigations reveal:
Hb 13.6 g/l
WBC 3.2 x 10 9 /L
Platelet 230 x 10 9 /L
ESR 25 mm/hr
Na 132 mmol/I

K 2.6 mmol/I

Urea 4 mmol/l

Creat 80 umol/l

Bicarbonate 35 mmol/l
alkaline phosphotase 85 iu/l (50-110)
bilirubin 14 (0=17) umol/l
AST 35 iu/l (5-40)

Albumin 32g/l

Which one of the following is the likely
underlying diagnosis?

1- Phaechromocytoma

2- Conns syndrome

3- Diabetes type 1

4- Anorexia nervosa

5- Addisons disease

Answer & Comments

Answer: 4- Anorexia nervosa

A low sodium, potassium and metabolic
alkalosis can be due to self induced vomiting.

Hence the clinical picture is most consistent
with anorexia nervosa.

[ Q: 1111 ] MRCPass - Endocrinology

A 65 year old man presents with
chest pain. His ECG show s anterior ST
elevation and he is thrombolysed with
tenecteplase. He has a history of type 2
diabetes and has a BM of 15 on admission. His
HbAlc is 10%.

Which one of the following is the most
appropriate therapy?

1- Maximise gliclazide dose

2- Metformin

3- Pioglitazone

4- Sliding scale insulin

5- 5% dextrose

Answer & Comments

Answer: 4- Sliding scale insulin

In diabetics who have had an Ml, the DIGAMI
study showed that intravenous insulin for 24
hours and subcutaneous insulin for 3 months
improved mortality rates for up to 3 years
after.

[ Q: 1112 ] MRCPass - Endocrinology

A 25 year old woman has polydipsia
and polyuria. She has had no history of
diabetes, but had a history of head injury
several years ago.

Investigations reveal:

sodium 155 (135-145)mmol/l

potassium 4.5 (3.5-4.9)mmol/l

calcium 2.35 (2.2-2.6)mmol/l

glucose 4.6 (3.0-6.0)mmol/l

Which one of the following is most likely to
confirm the diagnosis?

1- Oral glucose tolerance test

2- Water deprivation test

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3- Calcium levels

4- ADH levels

5- Trial of low dose DDAVP

Answer & Comments

Answer: 2- Water deprivation test

With the history of head injury, she may have
had pituitary damage causing cranial diabetes
insipidus, which may have manifested late. A
high sodium level is consistent with this. A
water deprivation test would help confirm
this, and challenge with DDAVP at the end of
the test may help to distinguish betw een
cranial and nephrogenic diabetes insipidus.

[ Q: 1113 ] MRCPass - Endocrinology

A 50 year old man presents with
episodes of sw eating and tremors, which are
relieved by glucose. He has gained 1 stone of
weight in the past 2 months and drinks
approximately 10 units of alcohol weekly.

His investigations show normal full blood
count, normal urea and electrolytes and a
fasting plasma glucose concentration of 3.8
mmol/l (3-6).

Whot is the next most appropriate
investigation ?

1- Insulin tolerance test

2- CT scan of pancreas

3- Insulin and C-peptide concentration

4- 24 hour urine catecholamines

5- Glucose tolerance test

Answer & Comments

Answer: 3- Insulin and C-peptide

concentration

If insulin and C-peptide levels both are
increased during a hypoglycaemic episode,
then insulinoma would be the cause. If the C-
peptide level was not raised but insulin level

is, then exogenous insulin use may be the
cause.

Insulin is derived from proinsulin (pictured) by
cleavage of the C-peptide structure (in blank

circles)

[ Q: 1114 ] MRCPass - Endocrinology

An 23 year old woman presents with
a history of 10 kg weight loss in the previous 6
months. She had menstruated only once
during this time. On examination she had fine
lanugo hair. She has a blood pressure of
110/60 mmHg.

Which one of the following would support the
likely clinical diagnosis?

1- Suppressed thyroid stimulating hormone
concentration

2- High plasma follicle stimulating hormone
concentration

3- Normal plasma cortisol concentration

4- Low plasma testosterone concentration

5- High SHBG concentration

Answer & Comments

Answer: 3- Normal plasma cortisol

concentration

The likely diagnosis is anorexia nervosa.
Weight loss and oligomenorrhoea are
associated features. FSH and LH
concentrations are usually low . TSH and
testosterone levels can be high. A normal
cortisol level would be consistent.

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[ Q: 1115 ] MRCPass - Endocrinology

A 45 year old lady presents with
lethargy, constipation and headaches. He has
a previous medical history of gastrinoma
diagnosed. Her calcium is 2.85 mmol/l,
phosphate is 0.6 mmol/l and PTH is 10.3
pmol/l (0.8-8.0).

Which of the following is the likely diagnosis?

1- Lung cancer

2- Secondary hyperparathyroidism

3- MEN type I

4- Adrenal tumour

5- Medullary thyroid carcinoma

Answer & Comments

Answer: 3- MEN type I

She has a high calcium, low phosphate and
raised PTH. The headaches could be caused by
a pituitary tumour. In association with a
pancreatic tumour (gastrinoma) and
parathyroid gland tumour, MEN I is the most
likely diagnosis. Diagnosis of gastrinoma is
made on the basis of a high fasting plasma
gastrin, high gastric acid secretion or a
demonstrable pancreatic or gastrointestinal
tumour - by CT or venous sampling for gastrin.

MULTIPLE

ENDOCRINE NEOPLASIA
TYPE I

prrufTARV

PARATHYROID

PANCREATIC

ISLET

[ Q: 1116 ] MRCPass - Endocrinology

A 30 year old man has a recent
history of head injury. Having recovered for
several weeks, he is no increasingly lethargic.

His investigations show :

Sodium 158 (133-145) mmol/l

Potassium 4.2 (3.5 - 5)mmol/l

Chloride 118 (100 - 112)mmol/l

Urea 6.0 (3 -7)pmol/l

Creatinine 85 (50 - 100)pmol/l

Urine Osmolality 80 mosmol/kg (50-1200)
mosmol/kg

Whot is the diagnosis?

1- Addison's disease

2- Syndrome of inappropriate antidiuretic
hormone secretion (SIADH)

3- Diabetes insipidus

4- Diabetes mellitus

5- Hyperchloraemic metabolic acidosis

Answer & Comments

Answer: 3- Diabetes insipidus

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The likely cause of this presentation is
Diabetes Insipidus. Urine osmolality is low and
there is hypernatraemia. Diabetes insipidus
can occur in patients with pituitary damage (in
this example from head injury) because of
insufficient anti diuretic hormone secretion.

[ Q: 1117 ] MRCPass - Endocrinology

A 55 year old woman was found by
the opthalmologist to have bitemporal
hemianopia and headaches. MRI scan shows a
pituitary tumour.

Which one of the following is the best
investigation to confirm the diagnosis of
acromegaly in this patient?

1- Insulin-like growth factor-1 (IGF-1)

2- Glucose tolerance test with growth
hormone concentrations

3- An insulin tolerance test with growth
hormone concentrations

4- 9am growth hormone concentrations

5- Growth hormone releasing hormone test

Answer & Comments

Answer: 2- Glucose tolerance test with growth
hormone concentrations

The diagnosis of acromegaly is confirmed by
inadequate suppression of growth hormone
concentrations below 2 mU/l in an oral
glucose tolerance test.

[ Q: 1118 ] MRCPass - Endocrinology

A 35 year old woman has a thyroid
goitre and complains of polyuria. Thyroid
function tests were normal, but
hypercalcaemia is noted. Her blood pressure is
155/105 mmHg. A chest radiograph is normal.

A thyroidectomy is performed, frozen sections
of several thyroid masses show a malignant
neoplasm composed of polygonal cells in
nests. Immunoperoxidase staining of the
sections is positive for calcitonin.

The diagnosis is likely to be:

1- Papillary thyroid carcinoma

2- Parathyroid hyperplasia

3- Multiple endocrine neoplasia type 2

4- Follicular thyroid carcinoma

5- Anaplastic thyroid carcinoma

Answer & Comments

Answer: 3- Multiple endocrine neoplasia type
2

Medullary thyroid cancer,

hyperparathyroidism, and

phaeochromocytoma form part of the MEN 2
syndrome.

MEN 2a is associated with medullary thyroid
carcinoma (MTC), parathyroid tumours (10-
20%) and pheochromocytoma (20-50%).

MEN 2b is associated with presentation of
medullary thyroid carcinoma, parathyroid
tumours and pheochromocytoma +
ganglioneuromatosis (pathognomonic), and
marfanoid habitus.

^ [ Q: 1119 ] MRCPass - Endocrinology

# A 25 year old patient has

palpitations. She has lost 1 stone of weight
over the past 3 months. On

examination, she has tremors in her hands
and palmar erythema. Knee and ankle reflexes
are brisk.

What is the likely diagnosis?

1- Acromegaly

2- Congenital adrenal hyperplasia

3- Phaeochromocytoma

4- Benign essential tremor

5- Thyrotoxicosis

Answer & Comments

Answer: 5- Thyrotoxicosis

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Recognised features of thyrotoxicosis are:
Weight loss, Palpitations, Dyspnoea,
Irritability, Psychosis, Tremor, Pruritus,
Diarrhoea, Palmar erythema, Hypercalcaemia,
Hyper-reflexia, Bone mineral loss and
Alopecia.

[ Q: 1120 ] MRCPass - Endocrinology

A 30 year old lady has lethargy,
fevers and palpitations. Her GP sends thyroid
function which show a Free T 4 of 30 pmol/l
and TSH of <0.01 mU/l. Her symptoms seem
to spontaneously resolve 6 weeks later.

Which one of the following is the most likely
diagnosis?

1- Multinodular goitre

2- Thyroid carcinoma

3- Grave's disease

4- Subacute thyroiditis

5- Iodine deficiency

Answer & Comments

Answer: 4- Subacute thyroiditis

Subacute thyroiditis is a transient thyroditis
which is thought to be of viral aetiology. There
is a sw ollen painful thyroid gland with
hyperthyroidism. This is usually followed by a
period of hypothyroidism with raised TSH
weeks later. Antithyroid medication is not
effective. Steroids can be used in severe cases.

Subacute Painless Thyroiditis

(Silent)

• . i- n 1

lit

[ Q: 1121 ] MRCPass - Endocrinology

A 40 year old woman has developed
secondary amenorrhoea, headaches and
bilateral galactorrhoea. She undergoes
investigations for a suspected pituitary
tumour. An MRI show s a 15 mm pituitary
tumour.

Which one of the following is the next most
appropriate step?

1- Skull X ray

2- Formal visual field testing

3- Transsphenoidal hypophysectomy

4- An oral glucose tolerance test

5- Octreotide treatment

Answer & Comments

Answer: 4- An oral glucose tolerance test

A macroadenoma (> 10mm) suggests a large
tumour. Often this may turn out to be
acromegaly or a macroprolactinoma and
hence oral glucose tolerance test is useful.

Octreotide should be used only if acromegaly
is confirmed, and Cabergoline for a
macroprolactinoma.

[ Q: 1122 ] MRCPass - Endocrinology

A 33 year old lady has a painless
thyroid nodule. Her mother had a similar
condition after which she had surgery and
thyroid replacement therapy.

Thyroid function tests show :

Free T 4 8 (10-24) pmol/l

TSH 7 (0.3-4) mU/l

What is the likely diagnosis?

1- Single nodular goitre

2- Grave's disease

3- Dyshormonogenetic goitre

4- Hashimoto's thyroiditis

5- Papillary thyroid carcinoma

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Answer & Comments

Answer: 4- Hashimoto's thyroiditis

Hashimo's thyroiditis can be familial. Long
standing thyroiditis leads to fibrotic changes
which can lead to a palpable lump.
Hypothyroidism is frequently associated. If
there is lymphadenopathy, then papillary
thyroid carcinoma should be considered).
Dyshormonogenetic goitre is very rare and
congenital. It tends to present in childhood /
teenage years with hypothyroidism.

^ [ Q: 1124 ] MRCPass - Endocrinology

f --—

# A 65 year old man has had type II
diabetes for 5 years. He has been lethargic
and undergone a series of tests which reveal
that he has type IV renal tubular acidosis.

Which one of the following should be used for
treatment?

1- Metyrapone

2- Lithium

3- Aminophylline

[ Q: 1123 ] MRCPass - Endocrinology

A 55 year old man is under
investigation for weakness of his legs,
pigmentation of the skin, hypertension and
glycosuria.

Results of serum cortisol estimations are:

Time Cortisol

0900 1000 nmol/l

2400 1050 nmol/l

After 48 hours of dexamethasone 8 mgs daily:

Time Cortisol

0900 1075 nmol/l

What is the likely diagnosis?

4- Fludrocortisone

5- Acetic Acid

Answer & Comments

Answer: 4- Fludrocortisone

Type 4 RTA is caused by a defect in the distal
tubule, but it is different from classic distal
RTA and proximal RTA because it results in
hyperkalaemia rather than hypokalaemia. RTA
type 4 is in effect hyporeninaemic
hypoaldosteronism.

It occurs when blood levels of aldosterone are
low or when the kidneys do not respond to it.
Fludrocortisone is usually effective as a form
of treatment.

1- Renal tubular acidosis

2- Conn's syndrome

3- Acromegaly

Type IV RTA may result from may result from
sickle cell disease, urinary tract obstruction,
lupus, amyloidosis, or transplantation.

4- Ectopic ACTH secretion

5- Panhypopituitarism

Answer & Comments

Answer: 4- Ectopic ACTH secretion

The patient has Cushing's syndrome with
failure to suppress cortisol levels during the
dexamethasone suppression test. This will
indicate either an adrenal tumour or an
ectopic source of ACTH.

[ Q: 1125 ] MRCPass - Endocrinology

* A 45 year old man presents with a
blood pressure of 180/95. He has a sodium of
149 mmol/l and potassium of 3.1 mmol/I.

Which one of the following diagnosis is most
likely?

1- Phaeochromocytoma

2- SIADH

3- 21-hyroxylase deficiency

4- Conn's syndrome

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5- Addison's disease

Answer & Comments

Answer: 4- Conn's syndrome

Conn's syndrome is the result of
mineralocorticoid excess due to an adrenal
adenoma (60%) or bilateral hyperplasia (40%).
A low potassium (< 3.5 mmol/L) accompanied
by metabolic alkalosis is characteristic. Renin
and aldosterone measurements may help to
determine the diagnosis. There is autonomous
aldosterone secretion in the presence of low
or suppressed renin activity.

Conn's syndrome tumour

[ Q: 1126 ] MRCPass - Endocrinology

fi -

* A 65 year old man with diet
controlled type 2 diabetes mellitus and a
creatinine of 350 umol/l.

utilization. Thus, some insulin must be
produced for it to have an effect. It is
associated hypoglycaemia although this side
effect is unusual. It is contraindicated in
subjects with renal failure, hepatic failure and
heart failure due to an association with lactic
acidosis.

[ Q: 1127 ] MRCPass - Endocrinology

A 52 year old female presents with a
history of weight loss, tremor and increased
sweating. Investigations reveal:

Free thyroxine 35 pmol/L (10-24)

TSH <0.1 mU

This patient is treated with radioactive iodine.

Which one of the following is on adverse effect
of rodiooctive iodine therapy?

1- Hyperthyroidism

2- Hypothyroidism

3- Goitre

4- Medullary thyroid carcinoma

5- Hypercalcaemia

Answer & Comments

Answer: 2- Hypothyroidism

Which of the following drugs should be
avoided if possible?

1- Isophane insulin

2- Actrapid insulin

3- Glimepiride

4- Gliclazide

5- Metformin

Answer & Comments

Answer: 5- Metformin

Metformin is a biguanide which acts by
improving insulin sensitivity through
mechanisms involinge hepatic

gluconeogenesis and improved muscle glucose

The major complication of treatment with
radioactive iodine is the progressive incidence
of hypothyroidism and thyroid replacement
may be necessary in the future.

[ Q: 1128 ] MRCPass - Endocrinology

A 45 year old Type 1 diabetic has an
annual checkup.

Which one of the following fundoscopy
findings warrants an urgent referral to the
opthalmologist?

1- Photocoagulation scars

2- Vitreous haemorrhage

3- Peripheral microaneurysms

4- Hard exudates close to the macula

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5- Blot haemorrhages

Answer & Comments

Answer: 2- Vitreous haemorrhage

Vitreous haemorrhage is a sign of proliferative
diabetic retinopathy but may also occur with
central retinal vein occlusion and age-related
macular degeneration with breakthrough
bleeding. Retinal detachment may occur and
vision may be impaired.

Vitreous Haemorrhage in diabetes

[ Q: 1129 ] MRCPass - Endocrinology

A 35 year old woman presented with
vomiting. Blood tests reveal high parathyroid
levels and hypercalcaemia.

Which one of the following is most likely to
have caused primary hyperparathyroidism?

1- Medullary thyroid carcinoma

2- Parathyroid adenoma

3- Parathyroid carcinoma

4- Papillary thyroid carcinoma

5- Follicular thyroid carcinoma

Answer & Comments

Answer: 2- Parathyroid adenoma

Primary hyperparathyroidism can be caused
by hyperplasia, carcinoma.

Adenomas are the most common,
representing 80-85% of cases.

A Tc-MIBI exam demonstrating a parathyroid

adenoma

[ Q: 1130 ] MRCPass - Endocrinology

A 68 year old man presents with
seizures. Past medical history includes a
smoking history of 35 cigarettes a day for
many years. His family report a 2 stone weight
loss over the past 8 months.

Serum electrolytes show :

Sodium 109 mmol/L (135-145)

Potassium 4.2 mmol/L (3.5-5.0)

Glucose 7 mmol/L

Urea 3.0 mmol/L (3.2-8.1)

These findings are most likely to be due to:

1- Epilepsy

2- Syndrome of inappropriate ADH secretion

3- Diuretics

4- Diabetes insipidus

5- Pituitary adenoma

Answer & Comments

Answer: 2- Syndrome of inappropriate ADH
secretion

The biochemistry points to a syndrome of
inappropriate ADH secretion, with a low
serum osmolality [2(Na + K) + urea + glucose].
The clinical picture is consistent with small cell
carcinoma of the lung, which is often
associated.

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Hyponatremia with hypo-osmolality

Elevated renal excretion of sodium (>20 mEq/L)

Normal volume status

Inappropriately elevated urine osmolality for the plasma
osmolality

SIADH

[ Q: 1131 ] MRCPass - Endocrinology

A 65 year old man presents with a
history of increased sw eating and daily
headaches. On examination the patient has
large spade like hands and the facial features
are exaggerated with large nose, prominent
jaw and thick lips.

Which screening test will yield the diagnosis?

1- Alpha feto protein

2- Prolactin level

3- Serum glucose

4- Plasma Insulin-like Growth Factor levels

5- Serum phosphate

testosterone 10 (11-36) nmol/L
LH 6 (0.5-9) IU/L
FSH 7 (1-8 ) IU/L

Early morning cortisol 450 (130-690) nmol/L

Growth hormone 2.5 (< 5.5) mlU/L

Which one of the following would support a
diagnosis of pituitary tumor?

1- Raised FSH and LH

2- High prolactin

3- Low GH

4- Low testosterone

5- Low cortisol

Answer & Comments

Answer: 2- High prolactin

A high prolactin level indicates likely
prolactinoma in this case causing the
macroadenoma seen on the CT scan.

Answer & Comments

[ Q: 1133 ] MRCPass - Endocrinology

Answer: 4- Plasma Insulin-like Growth Factor

h_]

A 35 year old female presents with

levels

Elevated GH levels increase IGF-1 blood levels.
Because IGF-1 levels are much more stable
over the course of the day, they are often a
more practical and reliable measure than GH
levels. Elevated IGF-1 levels almost alw ays
indicate acromegaly.

sw eatiness, tremors and palpitations.
Examination reveals a exopthalmos and a
goitre. Her GP requests TFT's which show a
TSH of 0.01mU/l, FT4 35 pmol/l, FT3 3.1
nmol/l. She has positive antithyroid
antibodies.

What is the likely diagnosis?

The oral glucose tolerance test is also used to
diagnose acromegaly, because ingestion of 75
g of the sugar glucose low ers blood GH levels
less than 2 ng/ml in healthy people. In
patients with acromegaly, this reduction does
not occur

1- Hashimoto's thyroiditis

2- Grave's disease

3- Iodine deficiency

4- Post radioiodine treatment

5- Papillary thyroid carcinoma

^ [ Q: 1132 ] MRCPass - Endocrinology

# A 20 year old man with headaches
had a CT scan which show s a 1.5 cm diameter
pituitary mass. His investigations show: Graves disease is the diagnosis - thyroid

, # . „ autoantibodies are increased. Almost 80% of

prolactin concentration 1,520 (50-450)mu/l

Answer & Comments

Answer: 2- Grave's disease

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patients have exopthalmos. Medical
treatment such as carbimazole or radioiodine
treatment are recommended rather than
surgery. There will be increased uptake on the
thyroid radioisotope scan.

Exopthalmos in Grave's disease

[ Q: 1134 ] MRCPass - Endocrinology

A 45-year-old female is under
investigation for excessive weight gain. She
has central obesity with abdominal striae. She
is hirsute.

A dexamethasone suppression test has been
performed with 8 mg dexamethasone a day
and the results are as follows:

Day 9 am Cortisol

0 970 nmol/L

2 335 nmol/l

3 110 nmol/l
What is the diagnosis?

1- Adrenal adenoma

2- Ectopic ACTH

3- Cushing's disease

4- Phaeochromocytoma

5- Conn's syndrome

Answer & Comments

Answer: 3- Cushing's disease

Cushing's disease is pituitary dependent
Cushing's (excessive ACTH secretion.

Cushing's syndrome refers to all forms of
Cushing's including adrenal adenoma.

In the dexamethasone suppression test
normal individuals suppress cortisol levels to <
50 nmol/L.

90 % of patients with pituitary dependent
disease suppress production of cortisol to < 50
% of the baseline cortisol level on day 2.

A Cushingoid patient

[ Q: 1135 ] MRCPass - Endocrinology

An 8 year old boy with bilateral
gynaecomastia is being investigated.

Which one of the features points towards
hypogonadotrophic hypogonadism being a
likely cause?

1- Small testes

2- Microphallus

3- Hypospadia

4- Hirsutism

5- Anosmia

Answer & Comments

Answer: 5- Anosmia

Hypospadias, micropenis, cryptorchidism can
all point tow ards genital developmental
disorder. Although hypogonadotrophic

hypogonadism can be caused by pituitary
disorders, a common presentation in

childhood is with anosmia (Kallman's

syndrome).

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^ [ Q: 1136 ] MRCPass - Endocrinology

# A 42 year old man has episodes of
dizziness, sw eating and tremors, which are
relieved by glucose. He has gained some
weight recently and drinks approximately 10
units of alcohol weekly.

His investigations show normal full blood
count, normal urea and electrolytes and a
fasting plasma glucose concentration of 3.5
mmol/I.

Whot is the best investigation to do?

1- 24 hour urine catecholamines

2- Glucose tolerance test

3- Water deprivation test

4- 72 hour fast

Answer & Comments

Answer: 3- Intravenous sodium nitroprusside

In the management of acute hypertensive
crisis of phaeochromocytoma as in this case,
IV administration of sodium nitroprusside,
nitroglycerine, or phentolamine can be used.

Preoperatively, the recommendation is
preoperative adrenergic-blockade of al and
a2 receptors with phenoxybenzamine (10-30
mg tw ice daily), or al receptors with prazosin
(starting with 1 to 2 mg three times daily.

Beta blockers can be useful for arrhythmias,
but should not be commenced before alpha
blockers because b-blockade alone can cause
marked hypertension.

5- MRI scan of the pituitary

Answer & Comments

Answer: 4- 72 hour fast

An insulinoma should be excluded (high
insulin levels, low C peptide levels during
hypoglycaemic episode) with a 72 hour fast.

[ Q: 1137 ] MRCPass - Endocrinology

A 35 year old woman is admitted
with a blood pressure of 230/120. She has a
sinus tachycardia of HR 160 with intermittent
runs of non sustained ventricular tachycardia.
24 hour urine show s increased Adrenaline of
720 (<80 nmol/24 hours) and Noradrenaline
2300 (<780 nmol/24 hours).

Which one of the following medications would
be most useful?

1- Intravenous labetalol

2- Intravenous amiodarone

3- Intravenous sodium nitroprusside

4- Intravenous diltiazem

5- Oral flecainide

Phaeochromocytoma

[ Q: 1138 ] MRCPass - Endocrinology

# A 40 year old lady has increasing
hirsutism. She is embarassed about having to
shave her chin and also her chest. Her voice is
becoming deeper.

Which one of the following is the most likely
diagnosis?

1- Drug induced hirsutism

2- Polycystic ovarian syndrome

3- Adrenal tumour

4- Congenital adrenal hyperplasia

5- Ovarian carcinoma

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Answer & Comments

Answer: 3- Adrenal tumour

urine osmolality high plasma osmolality. This
is most likely to be caused by lithium.

Rapid development of hirsutism is usually
caused by an adrenal tumour. There are high
testosterone or DHEA levels in the plasma.

MRI showing an adrenal tumour

[ Q: 1140 ] MRCPass - Endocrinology

A 45 year old woman has a blood
pressure of 210/100 mmHg and is assessed in
the hypertension clinic. She is complaining of
headaches and dizziness. Her fundi show silver
wiring and tortuosity of vessels.

Her blood tests are Hb 12 g/dl, WCC 7 x 10 9 /L,
Platelets 250 x 10 9 /L, urea 7 pmol/l, creatinine
75 pmol/l, sodium 146 mmol/I, potassium 2.7
mmol/I, cholesterol 4.5 mmol/l, triglyceride
1.8 mmol/l, bicarbonate 32 mmol/l.

Which one of the following investigations is
most important?

1- 24 hour urine for catecholamines

[ Q: 1139 ] MRCPass - Endocrinology

A 46 year male presents to the A&E
with complaints of polyuria. He mentions that
he has been passing about 4 litres of urine per
day. He has recently been prescribed a new
drug. Investigations show :

Serum sodium 141 mmol/l

Serum potassium 4.2 mmol/l

Plasma osmolality 290 mosmol/l (275-290)

Urine osmolality 330 mosmol/l (350-1000)

What drug was likely to have been prescribed?

1- Carbamazepine

2- Chlorpropamide

3- Fluoxetine

2- 24 hour tape recording

3- Renin-aldosterone levels

4- Glucose measurement

5- Urine electrolytes

Answer & Comments

Answer: 3- Renin-aldosterone levels

The combination of high sodium, low
potassium, high bicarbonate and hypertension
in this patient makes one suspicious of Conn's
syndrome. A high aldosterone and low renin
level makes Conn's a possible diagnosis. An
ambulant aldosterone/renin ratio of 25
ng/mU has been used as a cut off as being
high.

4- Furosemide

5- Lithium

Answer & Comments

Answer: 5- Lithium

[ Q: 1141 ] MRCPass - Endocrinology

A 52 year old lady presents with
palpitations. She has a Thyroid-stimulating
hormone of 0.01 mU/l (0.3-4.0) and free
thyroxine of 33 (10-24) pmol/l.

The patient has drug induced Diabetes
Insipidus based upon high urine output, low

Which one of the following conditions is
consistent with these results?

1- Radioiodine treatment

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2- Secondary hyperthyroidism

3- Secondary hypothyroidism

4- Iodine deficiency

5- Graves disease

Answer & Comments

Answer: 5- Graves disease

Graves disease is the most likely from the
picture of thyrotoxicosis. Secondary
hyperthyroidism results in increased secretion
of TSH (Thyroid Stimulating Hormone) by the
pituitary, therfore there is an increase in both
TSH and serum thyroxine.

[ Q: 1142 ] MRCPass - Endocrinology

A 18 year old man is referred to the
endocrine clinic by his GP because he had
poorly developed secondary sexual
characteristics. He describes anosmia. On
examination, he has lack of axillary or pubertal
hair, small sexual organs (testicular volumes of
approximately 5 ml).

Investigations reveal:

Testosterone 3.5 nmol/L (10-30)

Prolactin 350 mll/L (<450)

FSH 2.2 iu/L (1-7)

LH 1.8 iu/L (1-10)

What is the most likely diagnosis?

1- Testicular feminisation syndrome

2- Kallman's syndrome

3- Congenital adrenal hyperplasia

4- Marfan's syndrome

5- Klinefelter's syndrome

Answer & Comments

Answer: 2- Kallman's syndrome

X-linked Kallmann's syndrome (KS) is a genetic
disease characterized by anosmia and
hypogonadism due to impairment in the

development of olfactory axons and in the
migration of gonadotropin-releasing hormone
(GnRH)-producing neurons. 50% of the
patients also have unilateral renal agenesis.
Abnormalities of the sexual organs, mainly
cryptorchidism and testicular atrophy are
common.

[ Q: 1143 ] MRCPass - Endocrinology

A 55 year old patient with known
acromegaly is reviewed during a 6 monthly
outpatient appointment.

Which one of the following clinical features is
an indicator of disease activity?

1- Increase in the loss of visual field

2- Palpitations

3- Depression

4- Worsening nystagmus

5- Low oxygen saturations

Answer & Comments

Answer: 1- Increase in the loss of visual field

In acromegaly, the features of disease activity
are headache, increase in ring size, increased
denture size, increased sweating, skin tags,
glycosuria, hypertension and increased loss of
visual field.

[ Q: 1144 ] MRCPass - Endocrinology

A 66 year old man has no previous
medical history but presents with tendon
xanthomas. He is not on regular medication.
He drinks 5 pints of beer a day. A GP has
investigated has the following blood results:
cholesterol 6.5 (<5.2) mmol/I, triglycerides 1.9
(0.45-1.69) mmol/l. Thyroid function and
albumin are normal.

Which one of the following is most likely to be
the cause?

1- Oestrogen therapy

2- Familial hypercholesterolemia

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3- Alcoholism

4- SLE

5- Thyrotoxicosis

This is most likely due to inaccurate sampling
from a drip arm. In the other causes of
hyponatraemia, the plasma osmolality should
be low as well.

Answer & Comments

Answer: 3- Alcoholism

Causes of secondary hyperlipidaemia include:

Type 2 diabetes mellitus

■ chronic renal failure

■ alcoholism

■ drugs including: thiazides,

glucocorticoids, oestrogens,

cyclosporine, protease inhibitors

■ hypothyroidism
nephrotic syndrome.

[ Q: 1146 ] MRCPass - Endocrinology

* A 40 year old man attends a fertility
clinic. On examination, he is tall, slim and has
bilateral gynaecomastia.

Investigations show high levels of plasma
gonadotrophins.

What is the likely diagnosis?

1- Testicular feminisation syndrome

2- Klinefelter's syndrome

3- Marfan's syndrome

4- Noonan's syndrome

5- Homocystinuria

[ Q: 1145 ] MRCPass - Endocrinology

A 30 year old man has been
admitted diarrhoea. His blood pressure is
130/80 mmHg, and temperature 38°C.

Blood results show Na 118 mmol/I, K 2.8
mmol/I urea 2 pmol/l, creatinine 50 pmol/l,
chloride 70 mmol/I, bicarbonate 20 mmol/I.
Serum osmolality is 287 mosm/l and urine
osmolality is 700 mosm/l.

Which is the most likely diagnosis for the
hyponatraemia?

1- Addisonian crisis

2- Diarrhoea and salt loss

3- SIADH

4- Blood taken from a drip arm

5- Drugs

Answer & Comments

Answer: 4- Blood taken from a drip arm

There is hyponatraemia, hypokalaemia and
low urea with normal osmolality.

Answer & Comments

Answer: 2- Klinefelter's syndrome

Klinefelter's syndrome is the most common
cause of male hypogonadism with an
incidence of 1 in 1000 male births. Individuals
have an extra X chromosome. Usually, the
karyotype is 47, XXY. Accelerated atrophy of
germ cells before puberty results in sterility
with small, firm testes. Many patients are tall
with relatively long legs.

Behavioural disorders and delayed speech
development are common. Testosterone
therapy may be used to improve the
development of secondary sexual
characteristics.

^ [ Q: 1147 ] MRCPass - Endocrinology

mlt

# An 22 year old law yer has noted
have persistent polyuria in excess of 4 litres
per day. She mentions recently being involved
in an accident and sustained head injury which
she thinks she has recovered from.

Investigations reveal:

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potassium 4.2 mmol/l
calcium 2.3 (2.2-2.6) mmol/l
glucose 5.2 (3.0-6.0)

Which one of the following is the best way of
confirming the diagnosis?

1- Cortisol levels

2- Water deprivation test

3- ADH concentration

4- Measure autoantibodies to vasopressin

5- Therapeutic trial of low dose DDAVP

Answer & Comments

Answer: 2- Water deprivation test

The diagnosis is likely to be diabetes insipidus.
This can be confirmed a w ater deprivation
test where failure of urine concentration
would be expected. During this test a patient
is not allowed to drink and plasma ADH,
plasma osmolality and urine osmolality are
measured.

A therapeutic trial of DDAVP is only
appropriate if a diagnosis of Dl is confirmed
(on the water deprivation test) and helps to
differentiate betw een cranial or nephrogenic
diabetes insipidus.

[ Q: 1148 ] MRCPass - Endocrinology

A 30 year old woman with a 10-year
history of chronic renal insufficiency
secondary to bilateral obstructive
hydronephrosis presented for evaluation of
pain in the right hip. She had undergone
bilateral ureterostomies, but her creatinine
level remained chronically elevated.

An X ray revealed a fracture of the right
femoral neck necessitating internal fixation.
The patient also reported that the tips of her
fingers had increased in size over the past six
months.

On examination, she had clubbing of her
fingers with no skin lesions, joint sw elling or
tenderness.

What is the diagnosis?

1- Rheumatoid arthritis

2- Heberden's nodes

3- Osteopetrosis

4- Pseudohypoparathyroidism

5- Hyperparathyroidism

Answer & Comments

Answer: 5- Hyperparathyroidism

In this patient, hyperparathyroidism is
secondary to renal osteodystrophy. The hip
fracture and clubbing are consistent with
hyperparathyroidism.

[ Q: 1149 ] MRCPass - Endocrinology

A 72 year old woman complains of
muscle aches and pains and difficulty standing
up. Investigations show :

Serum calcium 1.9 mmol/L (2.2-2.6)

Phosphate 0.9 mmol/L (0.8-1.6)

Albumin 36 mg/L

Alkaline phosphatase 280 IU/L (30-230)

The most likely diagnosis is:

1- Primary hyperparathyroidism

2- Paget's disease

3- Chronic renal failure

4- Osteoporosis

5- Osteomalacia

Answer & Comments

Answer: 5- Osteomalacia

A low calcium, normal phosphate and mildly
raised alkaline phosphatase fits best with
osteomalacia (vitamin D deficiency). Features
of osteomalacia include bony pain and

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deformity, increased tendency to fracture,
proximal myopathy and hypocalcaemia. In
adults, treatment is with a daily dose of
calciferol (20-25 micrograms).

2- Commence a beta blocker

3- Add insulin

4- No action and repeat routine checks in 3
months

[ Q: 1150 ] MRCPass - Endocrinology

A 30 year old of average height and
weight presents with polyuria and thirst. He
has a blood glucose of 15 mmol/l. There is no
ketonuria and pH on the blood gas is 7.35.

How should he be treated?

1- Start metformin

2- A fasting blood glucose should be sent
before treatment

3- Subcutaneous insulin should be started

4- Commence on gliclazide and reassessment
with BM monitoring at home

5- Dietary advice, review in a month with
repeat glucose without any treatment

Answer & Comments

Answer: 4- Commence on gliclazide and
reassessment with BM monitoring at home

He is a type 1 diabetic but there are no
features of ketonuria or acidosis. He may have
some residual (3 islet cell function and hence
sulphonylureas may help to stimulate insulin
production.

[ Q: 1151 ] MRCPass - Endocrinology

A 45 year old type II diabetic patient
is screened at the clinic. His HBAlc is 6.7 %
and his BMs are varying betw een 5 to 10. He
has blood pressure of 135 / 70. There is no
signs of dot and blot haemorrhages on
fundoscopy.

He has urine dipstick showing protein ++ and
blood +. Creatinine is 80pmol/l.

Which one of the following is the best
management step?

1- Refer to a renal physician

5- Commence ACE inhibitor

Answer & Comments

Answer: 5- Commence ACE inhibitor

In diabetic patients with microalbuminaemia
demonstrated on urine dipstick, ACE inhibitors
have been show n to reduce progression tow
ards diabetic nephropathy.

[ Q: 1152 ] MRCPass - Endocrinology

A 62 year old type II diabetic patient
with a medial malleolus ulcer is being
examined.

Which one of the following indicates a bad
prognosis?

1- Flat foot

2- Absent pain sensation

3- Absent pulses

4- Absent vibration sense

5- Previous foot ulceration

Answer & Comments

Answer: 4- Absent vibration sense

All are associated with foot ulceration. Strong
predictors of foot ulceration are altered foot
sensation, foot deformities, and previous foot
ulcer or amputation, with altered foot
sensation being one of the strongest
predictors.

[ Q: 1153 ] MRCPass - Endocrinology

A 42 year old woman presents with a
6 month history of galactorrhoea. She also
complains of a 5 year history of dyspepsia.

Examination reveals a BMI of 23.5 kg/m 2 a
small amount of galactorrhoea was noticed.

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Slight neck enlargement was noticed during
examination.

Investigations show:

a prolactin concentration of 980 mU/l (50-500
mU/l)

an oestradiol of 85 pmol/l (130-500)
a LH of 3.1 mU/l (3.5-8)
a FSH of 2.8 mU/l (3-8)

Ultrasonography (revealed a parathyroid
enlargement and a 99mTc04/MIBI scan
showed tw o hyperplasic lesions.

Whot is the likely diagnosis?

1- Sheehan's syndrome

2- Acromegaly

3- Addison's disease

4- MEN type 1

5- Drug induced hyperprolactinaemia

Answer & Comments

Answer: 4- MEN type 1

The biochemical picture suggests a diagnosis
of a microprolactinoma. The patient is also
likely to have a parathyroid tumour. In the
presence of dyspepsia, a gastrinoma should be
considered to form an overall diagnosis of
MEN 1 [pituitary tumour, parathyroid tumour,
pancreatic tumour].

Hyperparathyroidism is the most common
manifestation of MEN 1, caused by
hyperplasia of multiple parathyroid glands.
Pancreatic islet cell tumors represent the
second most common manifestation of MEN 1
and occur in 80% of patients. Gastrinomas,
insulinomas or glucagonomas are all
pancreatic tumours which may occur.

[ Q: 1154 ] MRCPass - Endocrinology

# A 50 year old woman with
Cushingoid features has been shown to have
elevated early morning and midnight plasma

cortisol levels.

Which one of the following techniques is most
specific in differentiating between ectopic
Cushing's syndrome from pituitary dependent
Cushing's disease?

1- Low dose Dexamethasone suppression test

2- High dose Dexamethasone suppression test

3- Inferior petrosal sinus sampling

4- ACTH concentrations

5- Urine free cortisol

Answer & Comments

Answer: 3- Inferior petrosal sinus sampling

The inferior petrosal sinus sampling test, an
elevated central ACTH concentration
compared to a peripheral value (from arm
veins) indicates pituitary dependent Cushing's
disease. The test involves a microcatheter
being advanced through initially the femoral
vein and eventually into the inferior petrosal
sinuses which lie along the internal aspect of
the skull base which drain blood from the
pituitary gland.

Both High Dose Dex Suppression Test (HDDST)
and Inferior Petrosal Sinus Sampling are for
differentiating pituitary tumour and ectopic
cortisol production. Because the tumours are
sometimes very small an impossible to image
these tests are useful. They are based on
different principles - IPSS measuring ACTH
levels close to pituitary and peripherally.
HDDST measuring ACTH and cortisol levels
before and after giving Dex.

The most specific and most trouble is the IPSS
(this is nearly 100% specific), so if there is a
genuine question then its the best test. Thats
because of how the test is done - the IPSS
actually samples small amounts of blood from
close to the pituitary and then further
peripherally - so if there is a pit tumour it is
very likely to show high levels of ACTH close to
it and low er levels peripherally e.g. from the
arm.

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High Dose Dex Sup Test is much easier to do -
all you need is 2 days and keep taking blood
tests and give them dex tablets . How ever, if
you think about the High Dose test - its not
100% specific because a small number of
pituitary tumours will be so aggressive that
even High Dose Dex does not suppress its
ACTH production. Suppression is quoted at
75% for pituitary tumours with the HDDST.

Inferior petrosal sinus sampling

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[Q: 1155] MRCPass- Clinical
pharmacology

A 20 year old woman has been taking oral
medication for acne. She develops
polyarthritis, pleuritic chest pains and raised
liver enzyme tests.

Investigations show:

AST 90

ALT 180

bilirubin 19

antinuclear antibodies strongly positive at
1/640

Which drug is likely to have caused this?

1- Isotretinoin

5- Chlorpropramide

Answer & Comments

Answer: 5- Chlorpropramide

Oral contraceptive pills have an oestrogenic
effect.

Phenothiazines such as chlorpropramide and
thioridazine can have dopamine antagonistic
action) as does metoclopramide.

Bromocriptine is a dopamine agonist and this
inhibits prolactin release, [one way to
remember is this is that some of the drugs
which can make Parkinson's worse can also
cause galactorrhoea]

2- Oxytetracycline

3- Amoxycillin

4- Minocycline

5- Erythromycin

Answer & Comments

Answer: 4- Minocycline

Minocycline can cause drug induced SLE.
Procainamide, hydralazine and quinidine are
the commonest drugs causing drug induced
lupus. Muscle and joint pain and swelling, flu¬
like symptoms of fatigue and fever and
serositis are common symptoms.

[Q: 1156] MRCPass-Clinical
pharmacology

A 50 year old woman who has recently been
commenced on a new medication has
galactorrhoea.

Which one of the following medications is
associated with galactorrheoa?

1- Testosterone

2- Erythromycin

3- Rifampicin

4- Insulin

[Q: 1157] MRCPass-Clinical
pharmacology

A 45 year old man has drunk 10 pints of lager
beers a day for 20 years. He presents with
haemetemesis and has an OGD which shows
bleeding oesophageal varices.

Which one of the following medications is of
prognostic and mortality benefit in this clinical
situation?

1- Octreotide

2- Terlipressin

3- Amoxycillin and metronidazaole

4- Propanolol

5- Omeprazole

Answer & Comments

Answer: 2- Terlipressin

Octreotide and propanolol reduce rebleeding.
Trials have shown that vasopressin analogues
such as glypressin and terlipressin (34%
relative risk) provide mortality benefit.

Reference:

Cochrane Database Syst Rev. 2003;(1):CD002147.

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A 35 year old man has chest pains. He
mentions heavy cocaine use several hours
ago.

Which one of the following is a well known
side effect of cocaine?

1- Myocarditis

2- Pulmonary embolus

3- complete heart block

4- Cardiac ischaemia

5- Pericardial effusion

[Q: 1158] MRCPass-Clinical
pharmacology

Answer & Comments

Answer: 4- Cardiac ischaemia

Plasma concentration of sulphonylureas
(glibenclamide) is increased by fluconazole
and miconazole. This has led to the
hypoglycaemia in this case.

[Q: 1160] MRCPass-Clinical
pharmacology

A 33 year old lady who who has a past history
of treated hypertension is in her 3rd trimester
of pregnancy and requires on-going anti¬
hypertensive treatment.

Which medication should be avoided?

1- Nifedipine

2- Enalapril

3- Labetalol

4- Methyldopa

Cocaine is a stimulant and can cause agitation,
hyperthermia and hypertension in overdose. A
significant side effect in significant cocaine
overdose is coronary arterial vasoconstriction
leading to cardiac ischaemia.

[Q: 1159] MRCPass-Clinical
pharmacology

A 54 year old diabetic complained of
lightheadedness and a near collapse episode.
When his wife measured his blood sugar it
was 2.3. He was taking glibenclamide for the
diabetes.

Which one of the following drugs potentiates
hypoglycemia caused by glibenclamide?

1- Steroid

5- Hydralazine

Answer & Comments

Answer: 2- Enalapril

In pregnancy, angiotensin-converting enzyme
(ACE)-inhibitors should be avoided because
they may cause oligohydramnios, renal failure
and intra-uterine death.

[Q: 1161] MRCPass-Clinical
pharmacology

Which one of the following drugs affects the
opioid receptors present on the circular and
longitudinal muscles of the gut?

1- Ondansetron

2- Ranitidine

3- Phenytoin

4- Fluconazole

5- Aspirin

2- Omeprazole

3- Loperamide

4- Metoclopromide

5- Ranitidine

Answer & Comments

Answer: 4- Fluconazole

Answer & Comments

Answer: 3- Loperamide

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Loperamide acts on the opioid receptors along
the small intestine to decrease circular and
longitudinal muscle activity. Loperamide
exerts its antidiarrheal action by slowing
intestinal transit and increasing contact time,
and also by directly inhibiting fluid and
electrolyte secretion via stimulating salt and
water absorption.

^ [ Q: 1162 ] MRCPass - Clinical

* pharmacology

Antinuclear antibodies will develop in the
plasma of patients taking procainamide if the
patients are:

1- Fast acetylators

2- Slow acetylators

3- Thiopurine methyl transferase deficient

4- Slow oxidisers

5- Fast oxidisers

4- Adrenaline

5- Prochlorperazine

Answer & Comments

Answer: 2- Procyclidine

Dystonic reactions usually subsides within 24
hours following cessation of treatment and
can be treated with procyclidine 5-10 mg i.m.

They are well-recognized with dopamine
receptor antagonists (neuroleptics).
Phenothiazines, prochloperazine, haloperidol
and metclopramide are examples of drugs
which can cause dystonic reactions.

The newer antipsychotic drugs (e.g.
risperidone, onlanzapine) are more selective
for dopamine D2 receptors and therefore do
not usually cause these adverse effects. They
occur shortly after starting therapy,
particularly in girls and young women.

Answer & Comments

Answer: 2- Slow acetylators

Hydralazine and procainamide cause
antinuclear antibodies to appear in the plasma
of slow acetylators (drug induced lupus may
occur). Drugs that possess an amide group (-
NH2) are metabolised by acetylation. Slow
acetylators are likely to develop adverse
effects whereas rapid acetylators need higher
doses of drugs.

[Q: 1163] MRCPass-Clinical
pharmacology

A 35 year old woman is transferred from the
psychiatry ward with acute dystonia and
oculogyric crisis after being treated with
metoclopramide.

Which treatment should be started?

1- Phenytoin

2- Procyclidine

3- Dopamine

[Q: 1164] MRCPass-Clinical
pharmacology

A 45 year old man who has had a renal
transplant is concerned about the side effects
of ciclosporin.

Which of the following is a side effect?

1- Hypotension

2- Skin pigmentation

3- Alopecia

4- Gum hypertrophy

5- Cough

Answer & Comments

Answer: 4- Gum hypertrophy

Ciclosporin causes hirsutism and gum
hypertrophy (sodium valproate causes
alopecia). Concomitant use of erythromycin
can cause toxicity. It is a cyclic 11 aa
polypeptide.

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Gum hypertrophy

Whot drug is likely to have caused this?

1- Amiodarone

2- Hydroxychloroquine

3- Amocycillin

4- Minocycline

5- Tetracycline

Answer & Comments

Answer: 4- Minocycline

[Q: 1165] MRCPass-Clinical
pharmacology

A 70 year old man who is known to have
ischaemic heart disease is admitted with left
ventricular failure. He has been on NSAIDS for
arthritis.

What is likely to occur due to the fact that he
has been on NSAIDs?

1- Hyperkalaemia

This patient developed skin pigmentation in
her venous eczema due treatment of her acne
rosacea with minocycline.

I *1

A 62 year old man with a history of angina is
on atorvastatin.

Which one of the following is the correct
mechanism of action of statins?

[Q: 1167] MRCPass-Clinical
pharmacology

2- Renal tubular acidosis

1- HMGcoA reductase promoter

3- Reduced frusemide induced diuresis

4- Metabolic acidosis

2- LDL Receptor down regulation

3- Increase chylomicron levels

5- Increased bicarbonate excretion

Answer & Comments

Answer: 3- Reduced frusemide induced
diuresis

NSAIDS especially indomethacin reduce
frusemide induced diuresis, probably by
inhibiting the formation of prostaglandins in
the renal tubules.

[Q: 1166] MRCPass-Clinical
pharmacology

An 82 year lady had a history of a red facial
rash suffered venous eczema of legs. She was
treated for acne rosacea by her GP.

On examination, she had bluish pigmentation
on both the legs.

4- Decrease endogenous liver cholesterol
synthesis

5- Reduce triglyceride levels

Answer & Comments

Answer: 4- Decrease endogenous liver
cholesterol synthesis

Statins upregulate LDL receptors. They are
HMGcoA reductase inhibitor. This leads to
decreased liver cholesterol synthesis.

[Q: 1168] MRCPass-Clinical
pharmacology

A 28 year old woman was commenced on
Carbamazepine for epilepsy. She had admitted
to drinking 60 units a week and was also
advised to discontinue alcohol consumption.

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Therapeutic concentrations of Carbamazepine
were achieved within 5 days with a dose of
200mg daily but the dose needed to be
increased to 400 mg daily within two weeks to
achieve a therapeutic plasma concentration.

Which one of the following is likely to account
for this observation?

1- Auto-induction of liver enzymes

2- Auto-inhibition of liver enymes

3- Discontinuation of alcohol intake

4- Drug interaction with an oral contraceptive

5- Reduced bioavailablity of Carbamazepine

Answer & Comments

Answer: 1- Auto-induction of liver enzymes

In a patient who has discontinued alcohol,
hepatic enzymes are auto-induced. The
elimination of carbamazepine increases over
the first fewweeks because of the enzyme
induction.

Drugs which are acetylated include isoniazid,
hydralazine, dapsone, procainamide and
sulphasalazine. Slow acetylators have
increased risk of isoniazid induced peripheral
neuropathy, and procainamide induced SLE.
Fast acetylators are were considered more risk
of isoniazid induced hepatitis.

[Q: 1170] MRCPass- Clinical
pharmacology

A 65 year old man presents with chest pain.
His ECG shows ST eleveation consistent with
myocardial infarction and he is thrombolysed
with tenecteplase.

Which one drug has not been proven to reduce
future cardiovascular events and mortality?

1- Ramipil

2- Amlodipine

3- Atenolol

4- Aspirin

5- Simvastatin

[Q: 1169] MRCPass-Clinical
pharmacology

A 40 year old woman who had commenced on
a new drug has developed fevers and myalgia.

Which one of the following drugs is likely to
cause a systemic lupus like syndrome?

1- Amoxycillin

2- Pyrazinamide

3- Procainamide

4- Mesalazine

5- Methotrexate

Answer & Comments

Answer: 3- Procainamide

Answer & Comments

Answer: 2- Amlodipine

The four drugs which are shown to be of
benefit are aspirin (ISIS-2), atenolol (ISIS-1),
Ramipril (captopril studies in ISI-4),
simvastatin in 4S study. Amlodipine does not
provide mortality benefit.

[Q: 1171] MRCPass-Clinical
pharmacology

A 55 year old lady has atrial fibrillation. The
rate control of the condition is poor. The
medical student asked why a digoxin level was
measured 6 hours after a dose.

This is due to its:

A gene which is responsible for activity of
hepatic N acetyl transferase resulting in slow
and fast determines the likelihood of drug
induced lupus. 45% of UK population are slow
acetylators.

1- Rate of clearance

2- Rate of absorption

3- First pass metabolism

4- Rate of distribution

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5- Enzyme breakdown

Answer & Comments

Answer: 4- Rate of distribution

Following digoxin administration, a 6 to 8 hour
tissue distribution phase is observed.

This is followed by a much more gradual
decline in the serum concentration of the
drug, which is dependent on the elimination
of digoxin from the body.

Which one of the following is the most likely
drug?

1- Glue sniffing

2- Tricyclic antidepressant

3- Selective serotonin reuptake inhibitor

4- Methadone

5- Ethanol

Answer & Comments

Answer: 2- Tricyclic antidepressant

[Q: 1172] MRCPass- Clinical
pharmacology

A 55 year old with ischaemic heart disease has
a cholesterol of 6.5 mmol/I.

What drug should he be commenced on?

1- 5HT3 antagonist

2- Beta agonist

3- Anticholinesterase

4- HMGCoA inhibitors

5- Immunoglobulin

Answer & Comments

Answer: 4- HMGCoA inhibitors

Statins e.g. simvastatin, are HMGCoA
inhibitors. They increase the uptake of LDL
(not HDL) by the liver. HMGCoA inhibitors
should be offered to all patients with LDL
above 3 mmol/l with IHD to bring it down
below this level.

Myopathy is a serious side effect.

[Q: 1173] MRCPass-Clinical
pharmacology

An 18 year old girl presents with a drug
overdose. She is vomiting and generally
unwell. She does not have a history of drug
abuse, but has been depressed for the past 2
years. ECG shows a QT interval of 575ms
(normal < 470).

Out of these choices the most likely candidate
causing prolonged QT is a tricyclic
antidepressant. Amphetamine is also a
common cause (not listed here). Methadone
may cause QT prolongation at high doses, but
because of the case scenario (no history of
drug abuse) tricyclic antidepressant is the
better answer.

A 50 year old patient is hyperventilating. An
ABG shows pH 7.30, pC> 2 12 kPa, pCC >2 4.5 kPa,
BE -10 mmol/l.

What does base excess mean?

1- There is an excess amount of bicarbonate in
the system

2- Serum bicarbonate concentration is 10
below the normal range

3- The amount of base that would have to be
added or removed to obtain the pH
actually measured

4- Shows the amount of excess alkalosis which
might occur in a controlled environment

5- A high base excess is expected in a
hyperventilating patient

[Q: 1174] MRCPass-Clinical
pharmacology

Answer & Comments

Answer: 3- The amount of base that would
have to be added or removed to obtain the pH
actually measured

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The base excess is a figure calculated by many
blood gas machines to aid interpretation of
data.

The principles of the calculation are as follows:
predict the pH that would arise in normal
blood in the presence of the pC02 actually
measured; then calculate the amount of acid
or base that would have to be added to the
blood to change the calculated pH into the pH
as actually measured. This value is the base
deficit or excess, in mmol/l, which quantifies
the metabolic component (rather than the
respiratory) of acid-base disturbance.

[Q: 1175] MRCPass-Clinical
pharmacology

A 50 year old homeless man is brought to the
accident and emergency department by
ambulance. He is unconscious (GCS 5) with
pin-point pupils and a slow respiratory rate.

Immediate specific treatment should be:

1- Naloxone (0.4 mg) intravenously

2- N-acetyl cysteine (150 mg/kg over 15 min)
intravenously

recently been considered by the diabetologist
for insulin glargine.

Why might this be the case?

1- Poor control due to high blood sugars

2- He is working night shifts

3- Hypoglycaemic episodes

4- He is being considered for islet cell
transplantation

5- He is non compliant with insulin

Answer & Comments

Answer: 3- Hypoglycaemic episodes

Insulin glargine is a long-acting insulin
analogue, there is a smooth, prolonged
absorption profile with no peaks. As such, it is
a long-acting agent, suitable for providing a
basal level of insulin which mimics the normal
physiological state.

Its smooth profile reduces the risk of
hypoglycaemia, and when given at night,
provides good control of the fasting blood
glucose.

3- Gelofusin 1 litre immediately

4- Check paracetamol and salicylate levels
urgently

5- Conservative management and cardiac
monitoring

Answer & Comments

Answer: 1- Naloxone (0.4 mg) intravenously

[Q: 1177] MRCPass-Clinical
pharmacology

A 35 year old woman has overdosed on iron
tablets which were prescribed for her
mother's anaemia. She has had 2 generalised
seizures and has dark stools. Plasma iron
concentration was 80 mmol/l.

What drug should be used for treatment?

The clinical picture is consistent with an opioid
overdose, the treatment for which is
intravenous naloxone (0.4 mg), repeated up to
a total dose of 2 mg depending on the
response.

1- Desferrioxamine

2- Methylene blue

3- Flumazenil

4- N acetylcysteine

5- Naloxone

\ _ -J*

[Q: 1176] MRCPass-Clinical

pharmacology

Answer & Comments

A 25 year old Type I diabetic is currently on a Answer: 1- Desferrioxamine

human mixtard 30 twice a day. He has

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Iron overdose can lead to convulsions, Gl
haemorrhage, hepatic and renal failure,
pulmonary oedema and DIC. Gl haemorrhage
as early as a few hours after the overdose.

Desferrioxamine (maximum dose per day is 80
mg/kg) is appropriate for:

I. Patients with a serum iron level of 55-90
mmol/L with Gl haemorrhage

II. Patients with a serum iron > 90 mmol/L

[Q: 1178] MRCPass-Clinical
pharmacology

A 40 year old man works in a factory with
industrial chemicals. He has become confused
and depressed over the last 4 months.

On examination he has gait ataxia, tremor in
the limbs and reduced pain and temperature
sensation in his feet.

Which is the most likely chemical causing
these symptoms?

1- Lead

2- Bismuth

3- Manganese

4- Mercury

5- Carbon monoxide

Answer & Comments

calomel) are used in some products to inhibit
the growth of fungi and bacteria.

[Q: 1179] MRCPass-Clinical
pharmacology

A 35 year old lady was prescribed haloperidol
for radiation sickness.

What is the mechanism of action of
Haloperidol as an anti emetic?

1- HI receptor antagonism

2- D2 receptor antagonism at the
chemoreceptor trigger zone

3- D2 receptor antagonism at the brain centre

4- D2 receptor antagonism at the periphery

5- Reduced Gl motility

Answer & Comments

Answer: 2- D2 receptor antagonism at the
chemoreceptor trigger zone

The butyrophenones (haloperidol) are
dopamine antagonists and act centrally by
blocking the chemoreceptor trigger zone.
They are of considerable value for the
prophylaxis and treatment of nausea and
vomiting associated with diffuse neoplastic
disease, radiation sickness, and the emesis
caused by drugs such as opioids, general
anaesthetics, and cytotoxics.

Answer: 4- Mercury

The primary symptoms of mercury poisoning
are vague psychiatric ones. Short-time
memory can deteriorate. Organic mercury can
cross the blood-brain barrier and cause
irreversible nervous system and brain damage,
e.g., loss of motor control, numbness in limbs,
blindness, and inability to speak.

Elemental mercury (the silver liquid familiar
from thermometers) is the most common
occupational source. Exposure typically comes
from inhaling mercury vapors. Inorganic salts
of mercury (e.g., mercurous chloride, or

[Q: 1180] MRCPass-Clinical
pharmacology

A heroin addict who is on methadone program
was involved in a motor vehicle accident and
sustained multiple pelvic fractures.

How would you manage his analgesia?

1- Change analgesia to paracetamol with PRN
oramorph

2- Continue on methadone and add in
diclofenac

3- Continue methadone and titrate to pain
requirement

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4- Continue on methadone and add in
morphine as required

5- Discontinue methadone and start on
morphine

Answer & Comments

Answer: 5- Discontinue methadone and start
on morphine

Although methadone is an effective analgesic,
many clinicians prefer to select an alternative
opioid such as morphine, hydromorphone or
oxycodone to provide analgesia in
methadone-maintained patients to allow clear
distinction between treatment of addiction
and treatment of pain.

• i

A 50 year old man of African origin presents
with blood pressure 220/110mmHg. Urinalysis
is negative.

Fundoscopy shows AV nipping but no
haemorrhages or papilloedema.

Which of the following treatment options is
most appropriate?

1- Oral atenolol 50mg od and outpatient
review

2- Oral lisinopril 20mg and outpatient review

3- Oral amlodipine 10 mg od and outpatient
review

4- Urgent 24 hour catecholamines

5- Urgent admission for control of
hypertension

[Q: 1181] MRCPass- Clinical
pharmacology

Answer & Comments

Answer: 3- Oral amlodipine 10 mg od and
outpatient review

The diagnosis of accelerated hypertension
requires the finding of fundal haemorrhages
and exudates, with or without papilloedema.
The BTS guidelines recommends that older

(>55) and afro-carribean patients should have
C (calcium channel blockers) or D (diuretics).
Hence amlodipine is the best choice.

[Q: 1182] MRCPass-Clinical
pharmacology

A 75 year old woman has general lethargy.
Her drug list includes aspirin, atenolol,
bendrofluazide and chlorpropramide.

Investigations show:

Sodium 110 (137-144)

Potassium 3.1 (3.5-4.9)

Urea 6.2 (2.5-7.5)

Creatinine 95 micromol/L (60-110)

Glucose 12.2 (3.0-6.0)

ACTH levels : normal

chest Xray: normal

What is the likely cause of the hyponatraemia?

1- Cyclophosphamide

2- Bendrofluazide

3- Hypoadrenalism

4- Syndrome of inappropriate secretion of
antidiuretic hormone

5- Diabetes

Answer & Comments

Answer: 2- Bendrofluazide

Diuretics are most likely to cause combined
hyponatraemia and hypokalaemia, as in this
case. Combined hypokalaemia with
hyponatraemia occurs in very few conditions
such as increased antidiuretic hormone with
raised ACTH, vomiting, and diuretics.

[Q: 1183] MRCPass-Clinical
pharmacology

A 35 year old man attends the alcoholic
addictions clinic. He is keen to try to stop
drinking and is given some disulfram.

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What is the mode of action of the drug?

1- Reduces appetite for alcohol

2- Inhibits acetaldehyde dehydrogenase
activity

3- Reduces the likelihood of hangover

4- Inhibits alcohol dehydrogenase activity

5- Protects the liver

Answer & Comments

Answer: 2- Inhibits acetaldehyde

dehydrogenase activity

Alcohol is metabolized in the liver to form
acetaldehyde by alcohol dehydrogenase.
Acetaldehyde is then oxidized to acetate
(acetic acid) by acetaldehyde dehydrogenase
(AcDH). Disulfram produces irreversible
inhibition of this enzyme, resulting in
accumulation of acetaldehyde which may be
responsible for most of the signs and
symptoms occurring after ethanol ingestion in
disulfiram-treated patients.

What does this mean?

1- It is more easily bioavailable

2- It has a higher maximal response

3- It has a lower maximal response

4- Less drug is required to achieve the same
effect

5- There are more side effects

[Q: 1184] MRCPass-Clinical
pharmacology

more efficacious than drug B.

Drug A

Answer & Comments

Answer: 2- It has a higher maximal response

Efficacy relates to the maximal response that
can be produced by the drug when taken to
high levels. For example, the diuretic
furosemide eliminates much more salt and
water through urine than does the diuretic

chlorothiazide. Thus, furosemide has greater
efficacy than chlorothiazide.

Drug A Drug B

Log [Dose]

Drug A and Drug B have the same efficacy.

Drug A has greater potency than B or C
because the dose of B or C must be larger to
produce the same effect as A. Drug C has the
lowest efficacy and potency.

[Q: 1185] MRCPass-Clinical
pharmacology

A 65 year old woman treated for several years
for atrial fibrillation with digoxin, presents
with nausea and vomiting. ECG revealed
ventricular tachycardia and electrolytes
revealed hypokalemia.

Which one of the following signs indicates
digoxin toxicity?

1- Diarrhoea

2- Miosis

3- Tremor

4- Jaundice

5- Xanthopsia

Answer & Comments

Answer: 5- Xanthopsia

Hypokalaemia and hypomagnesaemia
increase the risk of digoxin toxicity.
Hemodialysis has no role in digitalis toxicity.
Administration of Fab antibody fragments is
the most effective treatment. Xanthopsia

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(yellow vision), nausea and vomiting are
common side effects.

[Q: 1186] MRCPass-Clinical
pharmacology

A 35 year old lady has been started on
azathioprine for rheumatoid arthritis. She
complains of lethargy and has a blood test
which shows: Hb 7.5 g/dl, WCC 3 x 10 9 /L,
platelets 45 x 10 9 /L.

The reaction is more likely if she :

1- Is drinking alcohol

2- Has thiopurine methyl transferase
deficiency

5- Corneal microdeposits

Answer & Comments

Answer: 4- Myopathy

The combination of amiodarone and a statin
increases the risk of developing myopathy.

[Q: 1188] MRCPass-Clinical
pharmacology

Which of the following drugs could couse o
raised prolactin level?

1- Metoclopramide

2- Ramipril

3- Has increased liver enzyme activity

3- Lansoprazole

4- Is on warfarin

4- Thiazides

5- Is a fast acetylator

5- Propanolol

Answer & Comments

Answer: 2- Has thiopurine methyl transferase
deficiency

The patient has developed a pancytopaenia
due to azathioprine toxicity. Approximately 1
in 300 Caucasians have thiopurine methyl
transferase (TPMT) deficiency.

TPMT is the enzyme that metabolises 6-
mercaptopurine and its deficiency results in
high risk of azathioprine toxicity.

A 55 year old lady has atrial fibrillation which
is being treated with amiodarone. She has also
been recently started on simvastatin.

This combination of drugs puts her at
increased the risk of developing:

1- Osteoporosis

2- Pulmonary fibrosis

3- Optic neuritis

4- Myopathy

[Q: 1187] MRCPass-Clinical
pharmacology

Answer & Comments

Answer: 1- Metoclopramide

The drugs that may increase prolactin levels
are: Phenothiazines, haloperidol,

metoclopramide, methyldopa and oestrogens.

[Q: 1189] MRCPass-Clinical
pharmacology

A 38 year old man with several medical
conditions was investigated for infertility.

Which one of the following drugs is most likely
to cause this?

1- Mesalazine

2- Sulfasalazine

3- Aspirin

4- Azathioprine

5- Amoxycillin

Answer & Comments

Answer: 2- Sulfasalazine

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Sulfasalazine, anabolic steroids,

cyclophosphamide, chlorambucil, busulfan
and cisplatin are drugs which cause
azoospermia.

4- Diltiazem

5- Metoprolol

Answer & Comments

^ [Q: 1190] MRCPass-Clinical

S pharmacology

A 45 year old man is admitted with an upper
lobe pneumonia. Investigations show
hyponatraemia and mildly deranged LFTs.

His CXR shows shadowing in the right mid and
upper zones. Therapy is started and 5 days
later he becomes acutely jaundiced with red
discolouration of the urine.

Which one of the following drugs is the likely
co use?

1- Rifampicin

2- Amoxycillin

3- Tetracycline

4- Erythromycin

5- Cefuroxime

Answer & Comments

Answer: 1- Rifampicin

The patient could have been commenced on
rifampicin for suspected Legionella
pneumonia or tuberculosis. Rifampicin is a
hepatic enzyme inducer and can lead to acute
jaundice, and patient should be told that urine
will turn a red discolouration.

Answer: 3- Anti digoxin antibodies

Brady arrhythmias and ventricular arrhythmias
can occur in digoxin overdose. Most often
seen are heart block with or without
supraventricular arrhythmias. Other effects
include vomiting, bradycardia, and
hyperkalemia. In toxicity, Digoxin Immune Fab
fragments (derived from specific antidigoxin
antibodies produced in sheep)can be given.

KMt04l

VW'—r'Vp*— f “7^

CAr-C-l

M - V «

ECG showing Digoxin effect causing reversed

Tick ST segments

[Q: 1192] MRCPass-Clinical
pharmacology

A 39 year old man presents with cocaine
overdose.

Which of the following should be avoided?

1- Nitrates

2- Beta blocker

3- Haloperidol

4- Diazepam

5- Amlodipine

[Q: 1191] MRCPass-Clinical

pharmacology

Answer & Comments

A 60 year old woman presents with a digoxin
overdose. Her ECG shows reversed tick ST
segments and she has a heart rate of 30 bpm.

Which of the following agents should be used?

1- Atropine

2- Charcoal

3- Anti digoxin antibodies

Answer: 2- Beta blocker

Treatment of acute cocaine intoxication can
be difficult. Although (3-blockers have been
used successfully to manage supraventricular
tachyarrhythmias, they also produce
unopposed alpha-stimulation in coronary
vasospasm, which can exacerbate cocaine-
induced hypertension and, at the same time,
cause reductions in coronary blood flow .

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[Q: 1193] MRCPass-Clinical
pharmacology

A 28 year old woman is 20 weeks
pregnant.She complains of fever and dysuria.
An MSU has showed a significant growth of
Gram negative bacilli.

Whot is the best choice antibiotic in this
situation?

1- Teicoplanin

2- Tazosin

3- Cefaclor

4- Trimethoprim

5- Ciprofloxacin

Answer & Comments

Answer: 3- Cefaclor

Trimethoprim is a folate antagonist and can
increases the risk of neural tube defects.
There is relative contraindication for
ciprofloxacin in pregnancy due to the possible
teratogenic effect. Augmentin, cefaclor,
nitrofurantoin and metronidazole are safe in
pregnancy.

[Q: 1194] MRCPass-Clinical
pharmacology

A 30 year old female presented with a 12-hr
history of progressive bluish discolouration of
lips and limbs. She denied ingesting or inhaling
any drug or substance. A high pa0 2 in the
presence of 'cyanosis' and 'dark blood' led to
suspicion of methaemoglobinaemia. Co¬
oximetry revealed the methaemoglobin level
to be 47%.

Which of the following is most likely to have
caused the condition?

1- Ascorbic acid

2- Charcoal

3- Methylene blue

4- Paracetamol

5- Chloroquine

Answer & Comments

Answer: 5- Chloroquine

Methaemoglobinaemia can be caused either
by a genetic defect in red cell metabolism or
haemoglobin structure, or acquired by a
variety of drugs and toxins. About forty
substances have been implicated in causing
this condition, the most prominent being
dapsone, nitrates, prilocaine, antimalarials,
sulphonamides and dyes.

Domestic causes of acquired
methaemoglobinaemia include ingestion of
food and water high in nitrites and nitrates,
exposure to aniline dyes in dyed blankets,
laundry markings, freshly dyed shoes, and
cleaning solution.

Standard pulse oximeters give spuriously low
readings in the presence of excess
methaemoglobin. Methylene blue is indicated
in any patient with symptoms and/or signs of
hypoxia (mental changes, tachycardia,
dyspnoea, chest pain). It is contraindicated in
G6PD deficiency. High flow oxygen should be
administered.

Methaemoglobinaemia causing cyanosis
(hand on the right of the picture)

[Q: 1195] MRCPass-Clinical
pharmacology

Which of the following describes the mode of
action of alendronate?

1- Osteoclast inhibition

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2- Osteoblast stimulation

3- Proximal convoluted tubule

3- Promotes collagen synthesis

4- Distal convoluted tubule

4- Causes hypocalcaemia

5- Promotes bone calcification

Answer & Comments

Answer: 1- Osteoclast inhibition

Bisphosphonates inhibit bone resorption
through inhibition of osteoclastic activity.

[Q: 1196] MRCPass- Clinical
pharmacology

An epileptic patient is on carbamazepine. He is
commenced on a new drug and noticed that
the frequency of his seizures has increased.

Which one of these drugs is likely to be
responsible?

1- Amoxycillin

2- Phenobarbitone

3- Tetracycline

4- Paracetamol

5- Digoxin

Answer & Comments

Answer: 2- Phenobarbitone

Liver enzyme inducers can interact and
increase breakdown of antiepileptic drugs.

5- Collecting duct

Answer & Comments

Answer: 4- Distal convoluted tubule

Thiazides block Na+ and Cl- reabsorption in
the distal tubule. There is usually passive Na+
and Cl- co transport. With this blocked,
natriuresis occur. The distal convoluted tubule
accounts for 5% of total sodium chloride
reabsorption.

[Q: 1198] MRCPass-Clinical
pharmacology

A 65 year old man has been taking
amiodarone 200 mg daily for troublesome
atrial fibrillation. He seems to be euthyroid
with no palpable goitre.

Investigations revealed: Serum Free T 4 - 21
pmol/L (9-26); Serum total T3 - 0.7 nmol/L
(0.9-2.8); Serum TSH - 6.3 mU/L (<5).

Which of the following explains these results?

1- Amiodarone-induced hypothyroidism

2- Amiodarone drug interaction with digoxin

3- 'Sick euthyroid' syndrome

4- TSH secreting tumour

5- Carbimazole ingestion

The enzyme inducers are PC BRAS - phenytoin,
carbamazepine, barbiturates

(phenobarbitone), rifampicin, alcohol and
sulphonamides.

[Q: 1197] MRCPass-Clinical
pharmacology

Which port of the renal system do thiazides
act on ?

1- Ascending loop of Henle

2- Descending loop of Henle

Answer & Comments

Answer: 1- Amiodarone-induced

hypothyroidism

This patient is likely to have amiodarone-
induced hypothyroidism.

There is normal T4 and a low T3 with elevated
TSH. This is because one of the effects of
amiodarone is to inhibit the peripheral
conversion of T4 to T3.

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[Q: 1199] MRCPass-Clinical
pharmacology

Drug A is more potent than drug 8. There is
more maximal effect

1- There is less maximal effect

2- What does this mean?

3- There is greater bioavailability

4- Less drug is required for the same effect

5- More side effects may occur

Answer & Comments

Answer: 4- Less drug is required for the same
effect

Which of the following drugs is appropriate for
prophylaxis against migraine?

1- Paracetamol

2- Lamotrigine

3- Clomiphene

4- Propanolol

5- Thyroxine

Answer & Comments

Answer: 4- Propanolol

Propranolol, sodium valproate, pizotifen and
amitriptyline can be used for prophylaxis in
migraine.

The potency of a drug relates to the amount
of drug needed to produce a given effect. Less
drug is hence required for the same effect for
a drug with higher potency. For example, if 5
milligrams of drug A relieves pain as
effectively as 10 milligrams of drug B, drug A is
twice as potent as drug B.

Drug A Drug B

Log [Dose]

Drug A and Drug B have the same efficacy.

Drug A has greater potency than B or C
because the dose of B or C must be larger to
produce the same effect as A. Drug C has the
lowest efficacy and potency.

[ Q: 1200 ] MRCPass - Clinical
Xf | pharmacology

A 65 year old woman has increasing frequency
of headaches. She has been diagnosed as
having migraines by the neurologist a year
ago.

| »1

A 50 year old patient has a history of COPD
and needs to be considered for
chemotherapy.

Which of the following drugs may cause lung
fibrosis and should be avoided?

1- 5-fluorouracil

2- Tamoxifen

3- Vincristine

4- Bleomycin

5- Cytarabine

[Q: 1201] MRCPass-Clinical
pharmacology

Answer & Comments

Answer: 4- Bleomycin

Busulphan, bleomycin and methotrexate are
cytotoxic agents which can cause lung fibrosis.
The changes are usually in the lower zones of
the lung.

[ Q: 1202 ] MRCPass - Clinical
pharmacology

A 58 year old man has a history of obesity,
gastro oesophageal reflux disease, lower back
pain and coronary disease. He presents with

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large, itchy wheals over the trunk and a
sensation of tightness in throat.

Which one of the following drugs is likely to
have triggered this skin eruption?

1- Nitrates

2- Atorvastatin

3- Lansoprazole

4- Aspirin

5- Paracetamol

Answer & Comments

Answer: 4- Aspirin

Among this list of drugs, aspirin is most likely
to cause drug related urticarial reaction
(NSAIDs as well can cause this).

[Q: 1204] MRCPass- Clinical
pharmacology

A 75 year old man presents to the hospital
with drowsiness and confusion. He is
tachycardic and tachypnoeic.

His pulse oximeter reading is 88% on room air
and he is not cyanosed. He has another family
member admitted with similar symptoms a
month ago.

Which one of the following is most likely?

1- Antifreeze poisoning

2- Carbon monoxide poisoning

3- Tuberculosis

4- Amitriptyline overdose

5- Atenolol overdose

[ Q: 1203 ] MRCPass - Clinical
pharmacology

A 65 year old woman has fast atrial fibrillation.
Her serum creatinine concentration is 330
umol/L.

What is the main factor that would aid in
choosing the loading dose ofdigoxin?

1- Lipid solubility

2- A. Absorption Volume of distribution

3- Renal clearance

4- Plasma half-life

5- First pass metabolism

Answer & Comments

Answer: 3- Renal clearance

The loading dose should take into account the
volume of distribution of a drug and also
clearance. In the case of digoxin, renal
clearance is the more important factor as
toxicity is much more likely when there is
moderate or severe renal impairment.

Answer & Comments

Answer: 2- Carbon monoxide poisoning

In carbon monoxide poisoning, it is essential
to measure CO levels, since pulse oximeters
cannot distinguish between COHb and Hb02.

[Q: 1205] MRCPass-Clinical
pharmacology

An 45 year old man who has hypertension. He
has recently become depressed from losing
his job and took an overdose of atenolol. He
has a heart rate of 35 bpm.

What should be given?

1- Sliding scale insulin

2- Metformin

3- Diltiazem

4- Atropine

5- Eprex

Answer & Comments

Answer: 4- Atropine

Bradycardia is a common feature of significant
B blocker overdose and should be treated by

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the administration of atropine. Intravenous
glucagon may also be given, particularly in
patients with haemodynamic compromise.
Temporary cardiac pacing may be necessary in
patients unresponsive to drug therapy.

[ Q: 1206 ] MRCPass - Clinical
pharmacology

A 25 year old man presents after ingesting a
drug at a disco. Investigations reveals a serum
creatine kinase of 15,000 IU/L (24-195)

Which one of the following drugs is most likely
to be responsible?

1- Lorazepam

2- Gamma hydroxy butyrate (GHB)

3- Ecstasy (MDMA)

4- Antifreeze

5- Diamorphine

Answer & Comments

Answer: 3- Hyperthermia

Cocaine stimulates the central nervous
system, causing agitation, dilated pupils,
tachycardia, hypertension, hallucinations,
hyperthermia, hypertonia, and hyperreflexia;
cardiac effects include chest pain(due to
vasospasm), myocardial infarction, and
arrhythmias.

[ Q: 1208 ] MRCPass - Clinical
pharmacology

A 75 year old man with atrial fibrillation has
been stable on warfarin for many years. He is
admitted with a epistaxis and his INR is found
to be 10.

Recent prescription of which of the following
drugs might explain this?

1- Barbiturates

Answer & Comments

Answer: 3- Ecstasy (MDMA)

The elevated Creatinine Kinase levels suggest
rhabdomyolysis. Features of acute MDMA
(ecstasy) toxicity include agitation,
tachycardia, hypertension, dilated pupils,
sweating, hyperthermia, disseminated
intravascular coagulation (DIC),

rhabdomyolysis and acute renal failure.

[Q: 1207] MRCPass-Clinical
pharmacology

A 43 year old man was brought to the A&E
confused and agitated after cocaine use.

Which of the following finding would be
consistent with cocaine abuse?

1- Hypothermia

2- Hyperkalemia

3- Hyperthermia

4- Hypokalemia

5- Hypernatremia

2- Ciprofloxacin

3- Griseofulvin

4- Phenytoin

5- Carbamazepine

Answer & Comments

Answer: 2- Ciprofloxacin

Ciprofloxacin is a liver enzyme inhibitor
(CYP450) and hence potentiates the action of
warfarin, leading to a high INR.

[ Q: 1209 ] MRCPass - Clinical
pharmacology

A 60 year old man has been started on Viagra
by his GP. The patient has symptoms of
angina.

Which one of the following drugs is
contraindicated?

1- Atenolol

2- Clopidogrel

3- Glyceryl trinitrate

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4- Simvasatin

5- Ramipril

Answer & Comments

Answer: 3- Glyceryl trinitrate

Both sildenafil (viagra) and nitrates have a
vasodilatory effect, hence potentially

2- HRT

3- Calcium gluconate

4- Ondansetron

5- Azathioprine

Answer & Comments

Answer: 1- Amitriptyline

cumulative hypotensive effect. Caution should
be taken in patients with ischaemic heart
disease and sildenafil.

[Q: 1210] MRCPass- Clinical
pharmacology

A 70 year old woman with ascites secondary
to carcinoma of the ovary is complaining of
abdominal distension and intermittent
vomiting.

The antiemetic of choice is:

1- Dexamethasone

Causes or triggering factors in oculogyric crisis
include: neuroleptics, benzodiazepines,

carbamazepine, chloroquine, cisplatin,

influenza vaccine, levodopa, lithium,
metoclopramide, nifedipine, reserpine,

tricyclics.

They occur shortly after starting therapy,
particularly in girls and young women as well
as the elderly. The problem usually subsides
within 24 hours following cessation of
treatment and can be treated with
procyclidine 5-10 mg i.m.

2- Cyclizine

3- Metoclopramide

4- Ondanestron

5- Haloperidol

Answer & Comments

Answer: 3- Metoclopramide

Metoclopramide as a prokinetic agent will
increase the rate of transit of food through
the gastrointestinal tract and alleviate her
symptoms.

A 25 year old lady presents with acute
dystonia and oculogyric crisis after being
treated with a drug.

Which one of the following drugs is most
likely?

1- Amitriptyline

[Q: 1211] MRCPass-Clinical
pharmacology

[Q: 1212] MRCPass-Clinical
pharmacology

A 25 year-old woman presents with acute
abdominal pain. She is diagnosed with an
acute exacerbation of acute intermittent
porphyria (AIP).

What is the most likely predisposing drug?
1- Barbiturates

2- Amoxycillin

3- Oral contraceptive pill

4- Chlorpromazine

5- Paracetamol

Answer & Comments

Answer: 3- Oral contraceptive pill

benzodiazepines, oral contraceptive pills,
sulphonamides (co-trimoxazole), phenytoin
and rifampicin.

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[Q: 1213] MRCPass-Clinical
pharmacology

A 70 year old man is assessed in the psychiatry
clinic. The SHO is concerned about lithium
toxicity.

Which of the following is o sign that his lithium
level is toxic?

1- Weight loss

2- Poor appetite

3- Xanthopsia

4- Tremors

5- Skin pigmentation

Answer & Comments

Answer: 4- Tremors

tremors, oliguria, blurred vision, diarrhoea,
vomiting, hyperreflexia, convulsions and
decreased consciousness.

[Q: 1214] MRCPass-Clinical
pharmacology

A 70 year old man is referred to the
rheumatology clinic because of inadequate
pain relief. He has osteoarthritis affecting both
hips. His GP has prescribed paracetamol and
codeine 30mg four times daily but he has
found little improvement in his pains.

[Q: 1215] MRCPass-Clinical
pharmacology

A 44 year old is on several

immunosuppresants.

Which one of the following is o colcineurin
inhibitor?

1- Sulphasalazine

2- Cyclophosphamide

3- Methotrexate

4- Cyclosporin

5- Azathioprine

Answer & Comments

Answer: 4- Cyclosporin

Examples of calcineurin inhibitors (CNIs) such
as ciclosporin and tacrolimus.

[Q: 1216] MRCPass-Clinical
pharmacology

A 40 year old patient who has depression is
being assessed. She was found to have a heart
rate of 140. Upon enquiry she takes diazepam
and dothiepin.

What should be done next?

1- Iv flumazenil

2- Iv naloxone

What is the likely cause?

1- Fast acetylator status

2- Slow acetylator status

3- Non compliance

4- Inadequate dose of Codeine

5- Interaction of codeine with paracetamol

Answer & Comments

Answer: 4- Inadequate dose of Codeine

Studies have shown that paracetamol lg
combined with codeine at dose of 60mg have
the best analgesic outcomes.

3- Echocardiogram

4- Electrocardiogram

5- Iv magnesium

Answer & Comments

Answer: 4- Electrocardiogram

Although neither drug on its own is
particularly implicated for QT prolongation,
the likelihood is increased in combination. An
ECG is the best initial assessment for a patient
with tachycardia to exclude ventricular
arrhythmia.

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A 50 year old lady has a diagnosis of
scleroderma. She complains of lethargy,
anorexia, heartburn and weight loss. Her
blood pressure is 150/100 on more than one
occasion. Urine dipstick shows protein ++. Her
investigations are as follows: urea is 9.5
mmol/l, Creatinine 125 umol/l, Na 138
mmol/l, K 4.2mmol/l.

Which medication should be used to treat
hypertension ?

1- Alpha blocker

2- Calcium antagonist

3- Thiazide

4- ACE inhibitor

5- Beta-blocker

[Q: 1217] MRCPass-Clinical
pharmacology

Answer & Comments

Answer: 4- ACE inhibitor

Renal involvement in systemic sclerosis
requires tight control of hypertension (which
may worsen the renal impairment) and ACE
inhibitors are the drugs of first choice.

[Q: 1218] MRCPass-Clinical
pharmacology

A 25 year old epileptic woman is now
pregnant and in the second trimester. She has
been taking sodium valproate for several
years with good control of epilepsy.

Which of the following is a significant risk with
sodium valproate?

1- Anaemia

2- Fetal neural tube defect

3- Hypoglycaemia

4- Weight gain

5- Abdominal striae

Answer & Comments

Answer: 2- Fetal neural tube defect

Sodium valproate is associated with a 1.5%
risk of neural tube defects. This may be
attributed in part to its effect in reducing
serum folate. Other abnormalities with
sodium valproate include: hypospadias, heart
defects, craniofacial and skeletal anomalies,
and developmental delay.

[Q: 1219] MRCPass-Clinical
pharmacology

A 35 year old man is brought to casualty from
a nightclub where he had collapsed following
ingestion of several tablets of ecstasy.

Which of the following is a recognised side
effect?

1- Urinary incontinence

2- Constipation

3- Bradycardia

4- Hyperthermia

5- Crying

Answer & Comments

Answer: 4- Hyperthermia

The main effects of ecstasy intoxication are
hypertension, tachycardia, increased
respiratory rate, hyperthermia and increased
sweating. More serious complications are
malignant hyperthermia, liver failure and
cerebral oedema.

[ Q: 1220 ] MRCPass - Clinical
pharmacology

A 25 year old man attends casualty 12 hours
after taking an overdose of 30 g of
paracetamol and 5 tablets of 3mg codeine. On
examination, he is drowsy with a Glasgow
Come Scale of 13. His pulse is 110 beats per
minute, blood pressure is 110/70 mmHg and

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he has pinpoint pupils, with saturations of
98% on air.

What is the best treatment option?

1- Naloxone

2- N-acetylcysteine

3- Haemodialysis

4- Flumazenil

5- Activated charcoal

Answer & Comments

Answer: 2- N-acetylcysteine

Although the patient has pinpoint pupils, he
had ingested 30g of paracetamol which is a
toxic dose (lethal if > 30g in people with
normal liver function). Hence N-acetylcysteine
is the best management option. His GCS and
respiratory rate (oxygen saturations) are not
significantly compromised, otherwise
naloxone would be the best option.

[Q: 1221] MRCPass-Clinical
pharmacology

A 30 year old man is on warfarin and is given
advice regarding foods.

Which one of these foods is a liver enzyme
inhibitor?

1- Rice

2- Potatoes

3- Grapefruit juice

4- Apple juice

5- Spinach

Answer & Comments

Answer: 3- Grapefruit juice

Grapefruit juice is an inhibitor of the enzyme
cytochrome P450 3YA.

[ Q: 1222 ] MRCPass - Clinical
pharmacology

A 30 year old lady has been on treatment for
depression. She complains of constipation. On
examination, she has a palpable goitre.

Her blood results are as follows:

Serum calcium 2.75 mmol/l
phosphate 0.7 mmol/l
TSH 18 mU/l

Free T 4 8 pmol/l

Which drug is likely to be responsible?

1- Paroxetine

2- Amitriptyline

3- Citalopram

4- Lithium

5- Venlafaxine

Answer & Comments

Answer: 4- Lithium

Lithium can cause hypercalcaemia and
hypothyroidism along with a goitre. The other
side effects are fine tremor, weight gain,
diabetes insipidus and cardiac arrhythmias.

[ Q: 1223 ] MRCPass - Clinical
pharmacology

A 50 year old man presents with painless
bilateral arm weakness and abdominal pain.
On examination he has bilateral wrist drop.

Which one of the following forms of poisoning
is likely?

1- Mercury

2- Lead

3- Arsenic

4- Carbon monoxide

5- Organophosphates

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Answer & Comments

Answer: 2- Lead

Blood lead levels over 10 micrograms/dL can
cause neurological damage. Peripheral
neuropathy and bilateral wrist drop is classic.
Severe lead poisoning can cause persistent
vomiting, seizures, coma, and death.

Ingestion of lead-based paint is the most
common source of lead poisoning in children.

3- Amyloid deposition

4- Interstitial nephritis

5- Mesangial thinning

Answer & Comments

Answer: 4- Interstitial nephritis

NSAIDS may cause interstitial nephritis,
glomerulonephritis and renal papillary
necrosis.

[Q: 1224] MRCPass-Clinical
pharmacology

A 60 year old woman who is on several drugs
has a potassium of 2.7 mmol/I.

Which one of the following drugs is likely to
couse hypokoloemio?

1- Ramipril

2- Hydrochlorothiazide

3- Amiloride

4- Losartan

5- Spironolactone

Answer & Comments

Answer: 2- Hydrochlorothiazide

ACE inhibitor (ramipril), angiotensin receptor
blocker (losartan), and potassium sparing
diuretics (amiloride, spironolactone) cause
hyperkalaemia. Thiazide diuretics do not
contribute to hyperkalaemia.

• t

A 40 year old woman who has been taking
NSAIDs has sudden deterioration of renal
function.

Which one of the following is the most likely
effect of NSAIDS on the kidney?

1- IgA nephropathy

2- Increased sensitivity to ADH

[Q: 1225] MRCPass-Clinical
pharmacology

[ Q: 1226 ] MRCPass - Clinical

i pharmacology

____--' s

An 18 year old female attends casualty 6
hours after ingesting approximately 30g of
Paracetamol and 360mg of Dihydrocodeine.

On examination, she is drowsy with a Glasgow
Coma Scale of 12. Her pulse is 100 beats per
minute, blood pressure is 110/66 mmHg and
she has pinpoint pupils, with saturations of
96% on air.

Whot is the most appropriate treatment for
this patient?

1- 10% Dextrose infusion

2- Activated charcoal by mouth

3- Gastric lavage

4- N-Acetylcysteine intravenously

5- Naloxone intravenously

Answer & Comments

Answer: 4- N-Acetylcysteine intravenously

The patient has decreased GCS but not severe
enough for naloxone.

In this case NAC treatment early will reduce
the likelihood of significant liver damage due
to paracetamol poisoning.

[Q: 1227] MRCPass-Clinical
pharmacology

A 20 year old university student has been

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hearing voices for a week. He thinks that his
girlfriend is trying to kill him. A week ago he
was at a disco and admits to having taken a
substance.

Which of these drugs could couse psychosis?

1- Cocaine

2- LSD

3- Marijuana

4- Amphetamines

5- Antifreeze

Answer & Comments

Answer: 4- Amphetamines

balance (replacement if she becomes
hypernatraemic or dehydrated from polyuria).

A 80 year old lady has end stage ovarian
carcinoma and has worsening significant
abdominal pains. Her symptoms had been
previously well controlled on oxycodone SR
40mg bd.

Whot should the onolgesio be altered to?

1- Im morphine

2- Oral tramadol

3- Oral codeine

[ Q: 1229 ] MRCPass - Clinical
pharmacology

Amphetamines (speed) is most likely to 4- Prn oxycodone

produce a schizophreniform type psychosis. _ _ . . . . . .. . .

5- Syringe driver with diamorphine

[ Q: 1228 ] MRCPass - Clinical
pharmacology

A 28 year old patient with poorly controlled
bipolar disorder is on 800 mg/day dose of
lithium. She complains of going to the toilet
frequently and also thirst.

Whot should be done?

1- Check thyroid function

2- Check calcium levels

3- Monitor electrolytes and fluid balance

4- Increase lithium doses

5- MRI of pituitary

Answer & Comments

Answer: 3- Monitor electrolytes and fluid
balance

Side effects of lithium are - tremor, muscle
weakness, hypothyroidism, hypereflexia,
ataxia, weight gain, leucocytosis, nephrogenic
diabetes insipidus. This patient has
nephrogenic diabetes insipidus, which can
persist even if lithium is discontinued, for
months or years. Hence the best management
will be medium term management of fluid

Answer & Comments

Answer: 5- Syringe driver with diamorphine

A syringe driver with the correct dose of
diamorphine according to the amount of
opiates the patient has had previously, with
further stat doses as necessary of s/c
diamorphine or oramorph can be used. Often
antiemetics (cyclizine) are added as well.

[ Q: 1230 ] MRCPass - Clinical
pharmacology

A 25 year old patient has the following results.

Sodium 122 mmol/I

Potassium 2.9 mmol/I

Urea 13 mmol/l

Creatinine 160 umol/l

Bicarbonate 12 mmol/l

Which drug is likely to be responsible?

1- Frusemide

2- Thiazide

3- Acetazolamide

4- Amiloride

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5- Metolazone

Answer & Comments

Answer: 3- Acetazolamide

1- Tiotropium

2- Aminophylline

3- Prednisolone

4- Salbutamol

Acetazolamide (carbonic anhydrase inhibitor)
can cause hyponatraemia, hypokalaemia,
worsen renal impairment and also a metabolic
acidosis. Thiazides tend to cause a metabolic
alkalosis.

5- Atrovent

Answer & Comments

Answer: 3- Prednisolone

• i

i j

A 60 year old lady presents to A&E with
confusion, headache and tinnitus. Her GP has
recently started her on an analgesic and there
is concern she may have taken an overdose.

Which of the following would most likely
explain her symptoms?

1- Dihydrocodeine

2- Diclofenac

3- Aspirin

4- Morphine sulphate tablets

5- Paracetamol

[Q: 1231] MRCPass-Clinical
pharmacology

Answer & Comments

Answer: 3- Aspirin

The patient has signs which would go with
iatrogenic Cushing's syndrome caused by long
term steroid therapy.

[ Q: 1233 ] MRCPass - Clinical
pharmacology

A 30 year old man with G6PD deficiency has to
be cautious when he need to take any
medication.

Which one of the following is associated with
high risk of haemolysis in a patient with G6PD
deficiency?

1- Amoxycillin

2- Trimethoprim

3- Nitrofurantoin

4- Metronidazole

5- Cefuroxime

Aspirin in excess can cause symptoms of
nausea, vomiting, headache, confusion and
tinnitus or hearing difficulties. Whilst the
dihydrocodeine and MST could cause
confusion, they would not cause the tinnitus.

Answer & Comments

Answer: 3- Nitrofurantoin

Drugs with high risk of haemolysis in Glucose-
e-phosphate dehydrogenase are:

[ Q: 1232 ] MRCPass - Clinical
pharmacology

A 45 year old woman with COPD has severe
bruising around her abdomen and upper
limbs. She also has centripetal obesity and is
hypertensive.

Which of the following of her medication is the
likely cause for her presentation?

dapsone

methylene blue

nitrofurantoin

primaquine

quinolones

sulphonamides

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Haemolysis in G6PD deficiency

[Q: 1234] MRCPass-Clinical
pharmacology

A 45 year old gentleman with type 2 diabetes
mellitus is brought in following an overdose of
oral hypoglycaemic agents. There is concern
that he may have taken an overdose of
metformin.

markers suggest a chest infection. She is also
in atrial fibrillation at a rate of 160/min. Her
electrolytes are normal (K 4.2 mmol/l).

As well os treating her pneumonia, she could
be digitalised with:

1- Two doses of Digoxin 0.5 mg orally with six
hours in between

2- Digoxin 0.25 mg orally once daily

3- Digoxin 1.0 mg intravenously stat

4- Digoxin 0.125 mg orally once daily

5- Digoxin 0.25 mg orally three times daily

Answer & Comments

Answer: 1- Two doses of Digoxin 0.5 mg orally
with six hours in between

Which of the following is the patient at risk of
developing?

1- Hyperglycaemia

2- Anaemia

The appropriate loading dose of Digoxin is two
doses of 0.5 mg (or 500 meg) with six hours in
between, then a maintenance dose of 0.125
mg or 0.25 mg a day thereafter.

3- Respiratory depression

4- Lactic acidosis

5- Methaemoglobinaemia

Answer & Comments

Answer: 4- Lactic acidosis

Metformin causes a type-B lactic acidosis in
overdose (high anion gap), especially in
patients who have co-ingested alcohol or who
have underlying renal or hepatic dysfunction.
Main symptoms of toxicity include
gastrointestinal upset and a severe lactic
acidosis. Hypoglycaemia is not often seen in
metformin overdose. If lactic acidosis occurs
following overdose, mortality is usually
greater than 50%.

[ Q: 1236 ] MRCPass - Clinical
pharmacology

A 62 year old woman has hypertension,
congestive cardiac failure, osteoarthritis,
urinary tract infections and depression. She
now feels non specifically unwell. Blood tests
show that she has acute renal failure, with
serum creatinine 850 micromol/l. Renal biopsy
shows acute interstitial nephritis.

Which medication is most likely to be
responsible for this condition?

1- Atenolol

2- Lisinopril

3- Ibuprofen

4- Amitriptyline

5- Paracetamol

• LJ

[Q: 1235] MRCPass
pharmacology

- Clinical

Answer & Comments

, 66

year old woman

presents with

Answer: 3- Ibuprofen

breathlessness. Chest X ray and inflammatory

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The drugs that most commonly cause acute
interstitial nephritis are penicillins, non¬
steroidal anti-inflammatory drugs and thiazide
diuretics.

A 55 year old man had suffered trauma to the
lumbar spine from a car accident. He had
spasticity and urinary symptoms. A drug was
prescribed, several weeks later he developed
jaundice.

What is the drug which was used?

1- Oxybutinin

2- Tizanidine

[Q: 1237] MRCPass-Clinical
pharmacology

Answer & Comments

Answer: 4- Amitriptyline

Patients who have taken an amitriptyline
overdose may present with dilated pupils, dry
mouth, drowsiness, sinus tachycardia, urinary
retention (palpable bladder), increased
tendon reflexes, and extensor plantar
responses. Hepatitis can also occur with
amitriptyline.

[ Q: 1239 ] MRCPass - Clinical
pharmacology

A 44 year old patient with previous tonic
clonic seizures is on sodium valproate 400mg
bd.

3- Baclofen

4- Diazepam

5- Ibuprofen

Answer & Comments

Answer: 2- Tizanidine

Which of the following is a common side-effect
of sodium valproate?

1- Gum hypertrophy

2- Weight loss

3- Hirsutism

4- Tremor

Tizanidine is an alpha 2 agonist drug. It is used
to treat muscle spasms. Its side effects are
nausea, anorexia and jaundice.

A 35 year old lady with depression is unwell
and brought to hospital by her friend. On
examination, she had jaundice, dry mouth and
was drowsy. She had a palpable bladder. Her
friend mentioned that she may have taken an
overdose.

Which drug may have been taken?

1- Paroxetine

2- Paracetamol

3- Ibuprofen

4- Amitriptyline

5- Codeine

[ Q: 1238 ] MRCPass - Clinical
pharmacology

5- Thrombocytosis

Answer & Comments

Answer: 4- Tremor

Side effects of sodium valproate are tremor,
weight gain, transient hair loss and
thrombocytopenia.

[Q: 1240] MRCPass-Clinical
pharmacology

Which of the following medications is an ADP
receptor antagonist?

1- Infliximab

2- Abxicimab

3- Tirofibran

4- Clopidogrel

5- Ezetimide

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Answer & Comments

Answer: 4- Clopidogrel

Clopidogrel is an ADP receptor antagonist.
Abxicimab and tirofibran are G2B3A
antagonists which are also used in unstable
coronary syndromes.

3- Treat with folinic Acid

4- Assess respiratory function

5- U + E measurement

Answer & Comments

Answer: 4- Assess respiratory function

[Q: 1241] MRCPass-Clinical
pharmacology

A 50 year old man was found collapsed on the
street. When in casualty, he was alert initially,
but then develops a grand mal convulsion.

Which is the most appropriate drug therapy?

1- Carbamazepine 200mg bd orally

2- Phenobarbitone 10 mg/kg body weight,
intravenously

3- Lorazepam 2 mg intravenously

4- Phenytoin intravenously at a rate of 100-
150 mg

5- Diazepam 10 mg intravenously

Answer & Comments

Answer: 3- Lorazepam 2 mg intravenously

First-line treatment should be with
intravenous benzodiazepine, with lorazepam
preferred to diazepam because of its longer
duration of action.

A 18 year old student was admitted eight
hours after taking an overdose of Diazepam
40mg, Methotrexate 400mg, which were her
mother's medications.

On examination, her Glasgow Coma Score was
10/15.

Which of the following is the most appropriate
immediate action?

1- Gastric lavage

2- Venous bicarbonate

[Q: 1242] MRCPass-Clinical
pharmacology

Her depressed GCS is likely to be due to
diazepam. The most appropriate inital
treatment would be to assess her respiratory
function. Following this, she should be given
folinic acid.

Methotrexate overdose is rare but potentially
fatal hepatotoxicity and renal toxicity are
reported. The appropriate treatment is folinic
acid (Leucovorin). Leucovorin can reverse
many effects of a methotrexate overdose but
must be taken soon after the methotrexate
was taken.

[Q: 1243] MRCPass-Clinical
pharmacology

A 45 year old man has right sided hemiparesis
from a CVA sustained a month ago. He now
has constant burning pains in the right arm
and leg.

Which of the following is likely to be effective
in relieving his symptoms?

1- Ibuprofen

2- Gabapentin

3- Tramadol

4- Oxycodone

5- Paracetamol

Answer & Comments

Answer: 2- Gabapentin

Although all the drugs can help from an
analgesic point of view , the best drug to treat
neuropathic pains is gabapentin. It resembles
gaba aminobutyric acid, a pain inhibitor in the
central nervous system, although its mode of
action is unclear.

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[Q: 1244] MRCPass-Clinical
pharmacology

A 40 year old patient presents with blurring of
the vision. He is on various medications.

Which one of the following drugs con couse
visual disturbance, despite being within
therapeutic range?

1- Diltiazem

2- Digoxin

3- Lisinopril

4- Carbamazepine

5- Amiodarone

Answer & Comments

Answer: 5- Amiodarone

Digoxin which is the other possible option
usually causes visual disturbance only in toxic
doses. Amiodarone causes reversible corneal
microdeposits.

[Q: 1245] MRCPass-Clinical
pharmacology

A 72 year old woman is assessed for visual
disturbance. She complains of visual haloes
and mild photophobia, which have been
present for a few weeks.

Which one of the following drugs is the most
likely cause of her symptoms?

1- Aspirin

2- Amlodipine

3- Amiodarone

4- Atenolol

5- Thiazide

Answer & Comments

Answer: 3- Amiodarone

Amiodarone may cause corneal
microdeposits, and symptoms include visual
haloes and photophobia.

Corneal Microdeposits seen with a slit lamp

[Q: 1246] MRCPass-Clinical
pharmacology

A 60 year old woman complains of nausea,
vomiting, headache, confusion and tinnitus.

What is she likely to have overdosed on?

1- Codeine

2- Tramadol

3- Oramorph

4- Aspirin

5- Metoclopramide

Answer & Comments

Answer: 4- Aspirin

Aspirin in excess causes symptoms of nausea,
vomiting, headache, confusion and tinnitus or
hearing difficulties. Tinnitus is unusual with
the other medications.

[Q: 1247] MRCPass-Clinical
pharmacology

A 50 year old man complains of pain and
swelling in the chest wall.

Which of the following drugs is likely to cause
gynaecomastia?

1- Atenolol

2- Frusemide

3- Cimetidine

4- Lansoprazole

5- Ramipril

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Answer & Comments

Answer: 3- Cimetidine

Drugs which can cause gynaecomastia are :

■ digoxin
oestrogens

■ spironolactone
cimetidine

■ verapamil
nifedipine

stimulating the osteoblasts to produce an
inhibitor of osteoclast formation. Osteoclast
inactivation is associated with bisphosphonate
uptake from the bone surface. Furthermore,
the bisphosphonates may act by shortening
the life span of the osteoclasts, possibly
through apoptosis.

1. Direct inhibition of osteoclasts when they take
up bisphosphonate present on bone.

^ [ Q: 1249 ] MRCPass - Clinical

jf | pharmacology

A 48 year man has impotence. He also has a
history of angina and hypertension.

Which one of the following drugs which he
takes would present a contraindication
towards Sildenafil?

1- Aspirin

2- Bendrofluazide

[Q: 1248] MRCPass-Clinical
pharmacology

A 60 year old lady is on alendronate once a
week.

Which of the following best describes the
mode of action of alendronate?

3- Isosorbide Mononitrate

4- Atenolol

5- Lisinopril

Answer & Comments

Answer: 3- Isosorbide Mononitrate

1- Binds vitamin D

2- Promotes collagen synthesis

3- Promotes bone matrix calcification

4- Inhibits osteoclastic activity

Nitrate use with Sildenafil (Viagra) are
contraindicated due to precipitant drops in
blood pressure. Viagra is also associated with
increases in intraocular pressure and hence
should be avoided in glaucoma.

5- Inhibits osteoblastic activity

* *J

[Q: 1250] MRCPass-Clinical

Answer & Comments

pharmacology

Answer: 4- Inhibits osteoclastic activity

Bisphosphonates acts at the cellular level.
They act directly or indirectly on the
osteoclasts. The effect can be on the
formation of osteoclasts and/or on their
activity. A decrease in osteoclast number can
occur either through direct action on
osteoclast precursors, or indirectly by

A man in his twenties is brought to the
accident and emergency department by
ambulance from a night club. He is has a GCS 5
with pin-point pupils and a slow respiratory
rate.

Immediate specific treatment should be:

1- N-acetyl cysteine (150 mg/kg over 15 min)
intravenously

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2- Insert NG tube and give activated charcoal

3- Dextrose (50 ml of 50% solution)
intravenously

4- Naloxone (0.4 mg) intravenously, repeated
if no effect

5- Flumazenil O.lmg/kg intravenously,
repeated if no effect

Answer & Comments

Answer: 4- Naloxone (0.4 mg) intravenously,
repeated if no effect

The likely diagnosis is (in view of the pinpoint
pupils) opioid overdose, the treatment for
which is intravenous naloxone (0.4 mg),
repeated up to a total dose of 2 mg depending
on clinical response.

• 1 J

A 22 year old man has taken a cocaine
overdose. He presents unwell to A&E.

Which one of the following is o major side
effect that should be observed for?

1- Hypothermia

2- Convulsions

3- Jaundice

4- Hypotension

5- Hypotonia

[Q: 1251] MRCPass- Clinical
pharmacology

Answer & Comments

Answer: 2- Convulsions

Convulsions, pyrexia, cardiorespiratory
depression, hypertension, agitation and
hypertonia are major side effects in cocaine
toxicity.

[Q: 1252] MRCPass-Clinical
pharmacology

A 65 year old man with atrial fibrillation and
mitral valve disease has been stable on

warfarin for many years. He is admitted with a
severe epistaxis and his INR is found to be
grossly elevated at 9.

Recent prescription of which of the following
drugs could explain this?

1- Barbiturates

2- Phenytoin

3- Rifampicin

4- Ciprofloxacin

5- Griseofulvin

Answer & Comments

Answer: 4- Ciprofloxacin

Warfarin is metabolized by the cytochrome
P450 enzyme system. Ciprofloxacin inhibits
CYP450 (liver enzyme inhibitor) and hence
potentiates the action of warfarin, which
could explain this presentation with bleeding
and high INR.

A 28 year old Type I diabetic is currently on a
basal-bolus regime, comprising twice a day
basal Isophane insulin, complemented by
short-acting insulin at meal times. He is
exploring new insulin regimes as he works
night shifts.

Which form of insulin is recommended?

1- Lispro

2- Mixtard 50

3- Mixtard 30

4- Actrapid

5- Insulin glargine

[Q: 1253] MRCPass-Clinical
pharmacology

Answer & Comments

Answer: 5- Insulin glargine

Insulin glargine is a long-acting insulin
analogue, produced by modifying the
chemical structure of insulin. This gives it a

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prolonged absorption profile with no peaks.
When given at night, it provides good control
of the fasting blood glucose and reduces the
risk if hypoglycaemia

3- 160 mg with 10 mg prn

4- 80 mg with 15 mg prn

5- 80 mg with 1 mg prn

[Q: 1254] MRCPass- Clinical
pharmacology

A 60 year old man is unwell having ingested a
bottle of dye. On examination, he is afebrile
but has tachypnea, cyanosis, and drowsiness.
He is given 100% oxygen but does not
improve. A lab test confirms methaemoglobin
levels >70%.

Whot should be given?

1- Hyperbaric oxygen

2- Ibuprofen

3- Haemodialysis

4- 10% glucose infusion

5- Methylene blue

Answer & Comments

Answer: 5- Methylene blue

Methaemoglobinaemia is a cause of cyanosis
because it causes the formation of reduced Hb
>1.5 g/dl. Chemicals which are oxidising
agents may cause this e.g. aniline dyes,
chlorates, nitrates, nitrophenols, primaquine
and sulphonamides. Treatment is with
methylene blue if methaemoglobin >3.0g/dL.

A 60 year old patient with carcinoma of the
colon has good pain control on MST 120 mg
bd. She is admitted with increasing weakness
and has difficulty with swallowing tablets. It is
therefore decided to convert her to a 24-hour
diamorphine syringe driver.

The correct dose of diamorphine is:

1- 160 mg with 30 mg prn

2- 160 mg with 20 mg prn

[Q: 1255] MRCPass-Clinical
pharmacology

Answer & Comments

Answer: 4- 80 mg with 15 mg prn

The total morphine dose is 240mg. The 24
hour diamorphine dose should be 1/3 of the
24 hour morphine dose, which is 80mg. The
PRN dose should be 1/6 of the total 24 hour
diamorphine dose, which is 13.3mg, rounded
up to 15 mg.

[Q: 1256] MRCPass-Clinical
pharmacology

Which one of the following drugs is associated
with both a raised anion and osmolar gap?

1- Aspirin

2- Ethanol

3- Phenytoin

4- Cyanide

5- Metformin

Answer & Comments

Answer: 2- Ethanol

The anion gap is calculated as (Na+ + K+) - (Cl-
+ HC03-). It is normally between 10 to 16.

Drug causes of a raised anion gap following
overdose include ethanol, salicylates,
paracetamol, metformin, cyanide and
isoniazid.

Calculation of plasma osmolality is: 2(Na+ +
K+) + Urea + Glucose. Drug causes of a raised
osmolar gap include ethanol, ethylene glycol
and methanol.

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• J

A 55 year old man who has rheumatoid
arthritis is referred by the GP for lethargy. He
has been on weekly injections.

A full blood count showed :

Hb 6.6 g/dl

MCV 82 fl

WCC 0.8 x 10 9 /L

Pit 35 x 10 9 /L

He has noticed a sore throat for 2 days and
also observed a purpuric rash over his
abdomen.

Which is the following is the most likely drug
to have caused this?

1- Penicillamine

2- Ibuprofen

3- Gold

4- Etanercept

5- Infliximab

[Q: 1257] MRCPass-Clinical
pharmacology

Answer & Comments

Answer: 3- Gold

The patient describes features of bone
marrow suppression (anaemia, leukopenia
and thrombocytopenia) induced by one of the
disease modifying anti-rheumatic drugs
(DMARDs). In this case, gold is most likely to
be given as a weekly injection.

[Q: 1258] MRCPass-Clinical
pharmacology

A 70 year old Caucasian patient was referred
by the GP due to recordings of blood pressure
of 180/100 mmHg initially and recordings of
170/95 and 170/90 when repeated 3 months
later. Urine dipstick shows no protein and no
blood.

Which agent should be commenced?

1- Atenolol

2- Bendrofluazide

3- Ramipril

4- Losartan

5- Moxonidine

Answer & Comments

Answer: 2- Bendrofluazide

In a patient of this age group a diuretic e.g.
bendrofluazide should be commenced first.
Followihg BHS criteria - Older and Black
patients could have either a C (calcium
channel blocker) or D (diuretic).

[Q: 1259] MRCPass-Clinical
pharmacology

A 22 year old lady who is on oral
contraceptives is seeking advice regarding her
medication.

Which of the following may make the
contraceptive LESS effective?

1- Erythromycin

2- Ketoconazole

3- Isoniazid

4- Gliclazide

5- Valproate

Answer & Comments

Answer: 4- Gliclazide

Gliclazide is a sulphonylurea which is a liver
enzyme inducer. The rest of the options are
liver enzyme inhibitors.

LIVER ENZYME INDUCERS (PCBRAS):

Phenytoin

■ Carbamazepine

■ Barbiturates

■ Rifampicin
Alcohol

Sulphonylureas

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[ Q: 1260 ] MRCPass - Clinical
pharmacology

A 30 year old lady has taken overdoses of
several drugs, and a casualty officer is
considering administration of charcoal.

Which of the following drugs would not be
adsorbed by activated charcoal?

1- Paracetamol

2- Salicylates

3- Theophylline

4- Digoxin

5- Lithium

Answer & Comments

Answer: 5- Lithium

Ethanol, ethylene glycol, iron, gold, mercury,
lithium, many acids and alkalis are not
adsorbed by activated charcoal. Activated
charcoal binds most other drugs that are
commonly used in poisonings.

[Q: 1261] MRCPass-Clinical
pharmacology

A 58 year old woman has been on Nifedipine
for hypertension. She mentions several
possible side effects which she blames the
medication for.

Which one of the following is a side effect with
Nifedipine?

1- Gum hypertrophy

2- Hirsutism

3- Bone marrow suppression

4- Dry cough

5- Weight loss

Side effects of nifedipine are gum hyperplasia,
headache, myalgia, tremors, cholestatic
jaundice and visual disturbance.

A 25 year old woman with no significant past
medical history, presents 20 weeks into
pregnancy with a painful swollen calf.
Ultrasound examination confirms that she has
a deep venous thrombosis.

How should this be managed up to the time of
delivery?

1- Initiate and then continue treatment with
warfarin until delivery

2- Initiate and then continue treatment with
heparin until delivery

3- No anticoagulation

4- Initiate treatment with both heparin and
warfarin and then continue until delivery

5- Initiate treatment with heparin, and
convert to warfarin, continued until after
delivery

[ Q: 1262 ] MRCPass - Clinical
pharmacology

Answer & Comments

Answer: 2- Initiate and then continue
treatment with heparin until delivery

Warfarin in the first trimester can cause fetal
hypoplasia of the nose and limbs. After this
period warfarin is associated with neurological
damage - mental retardation, microcephaly,
optic atrophy and blindness. There is an
option to convert from heparin to warfarin in
the third trimester, but the patient will have
to be re-converted back to heparin before
delivery.

Answer & Comments

Answer: 1- Gum hypertrophy

[ Q: 1263 ] MRCPass - Clinical
pharmacology

A 60 year old man with adenocarcinoma of
the colon has been taking morphine sulphate
continus (MST) 100 mg B.d. for 3 months.

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Following a course of chemotherapy including
oxaliplatin and 5 Fluorouracil, he developed a
2 day history of acute frequent diarrhoea.

The diarrhoea discontinued but he presents
with a 5 day history of drowsiness, lethargy
and ankle oedema.

Examination reveals pin point pupils.

Whot is the most likely cause of the
symptoms?

1- Metastatic disease

2- Interaction between chemotherapy and
morphine

3- Excessive antiemetic use

4- Renal failure leading to accumulation of
morphine

5- Rifampicin

Answer & Comments

Answer: 2- Ciprofloxacin

Liver enzyme inhibitors are omeprazole,
disulfram, erythromycin, valproate, isoniazid,
cimetidine, ciprofloxacin, ethanol and
sulphonamides.

^ [ Q: 1265 ] MRCPass - Clinical

S pharmacology

/ I- -- - - , | . ■„ . ........ .... -~

—

receptor blockers are used in hypertension
and prostate hypertrophy.

Which one of the following occurs with
stimulation of alpha receptors?

5- Liver failure due to opiates

Answer & Comments

Answer: 4- Renal failure leading to
accumulation of morphine

Renal failure can accentuate the effects of
opiates as in this instance, leading to
drowsiness and pinpoint pupils. In this case
the diarrhoea may have been caused by
chemotherapy.

^ [Q: 1264] MRCPass-Clinical

" pharmacology

A 60 year old woman with atrial fibrillation
and previous transient ischaemic attacks has
been on warfarin for several years. She
complains of excessive bleeding and presents
for a review . The INR result was 9. Upon
further enquiry, she mentions having been on
a new drug recently.

Which of the following is the most likely
co use?

1- Carbamazepine

2- Ciprofloxacin

3- Theophylline

4- Sulphonylurea

1- Bronchoconstriction

2- Increase in gut motility

3- Vasoconstriction

4- Uterus relaxation

5- Increase in pancreatic exocrine secretion

Answer & Comments

Answer: 3- Vasoconstriction

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lllLTl'HM.ll

[ Q: 1266 ] MRCPass - Clinical
pharmacology

A 60 year old lady who has significant
respiratory disease is on long term steroids.
Her bone mineral density is low . She has been
commenced on vitamin D and calcium
supplements.

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Which of the following would most likely be
recommended os treatment for corticosteroid-
induced osteoporosis?

1- Vitamin A

2- Vitamin C

3- Infliximab

4- Hormone replacement therapy

5- Erythropoietin

Answer & Comments

Answer: 4- Hormone replacement therapy

Hormone replacement therapy should be
recommended for postmenopausal women,
unless contraindicated.

Although calcium does not completely
suppress bone loss, patients given high-dose
inhaled or systemic corticosteroids should
have a calcium intake of at least 1,000
mg/day. Patients receiving limited sun
exposure, especially during the winter, may
benefit from supplements containing 400
lU/day of vitamin D. Although supplemental
calcium and vitamin D may counteract the
effects of corticosteroids on calcium transport,
studies have shown that they do not
completely eliminate corticosteroid-induced
bone loss.

[Q: 1267] MRCPass-Clinical
pharmacology

A 60 year old woman has increasing frequency
of migraine attacks despite NSAIDs, and has
been referred for further treatment.

Which one of the following drugs would be
appropriate for acute treatment against
migraine?

1- Sodium valproate

2- Propranolol

3- Amitriptyline

4- Pizotifen

5- Sumatriptan

Answer & Comments

Answer: 5- Sumatriptan

Sumatriptan is a 5HT1 agonist and may be
useful in the treatment of acute migraine
attacks, is available in injectable, intranasal,
and oral formulations. Ergotamine tartrate is
also effective in acute migraine. Propanolol,
valproate, NSAIDs, amitriptyline, pizotifen and
gabapentin are effective as prophylactic drugs
in migraine.

[ Q: 1268 ] MRCPass - Clinical
pharmacology

A 70 year old man has a creatinine of 350
umol/l.

Which one of the following drugs is likely to
worsen the renal failure?

1- Erythromycin

2- Sulfasalazine

3- Paracetamol

4- Olanzepine

5- Omeprazole

Answer & Comments

Answer: 2- Sulfasalazine

Sulfasalazine, NSAIDS, allopurinol, and ACE
inhibitors are examples of nephrotoxic drugs.

A 35 year old man presents following an
overdose with amitryptiline and
anticholinergic syndrome is suspected.

Which one of the following is likely?

1- Urinary incontinence

2- Mydriasis

3- Pale skin

4- Bradycardia

5- The patient is calm

[ Q: 1269 ] MRCPass - Clinical
pharmacology

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Answer & Comments

Answer: 2- Mydriasis

5- Oral nifedipine capsules 20mg tds if
hypertension confirmed over 1-2 weeks

Anticholinergic syndrome occurs following
overdose with drugs that have anticholinergic
activity.

Examples of these are tricyclic
antidepressants, antihistamines and atropine.

Features include flushed skin, urinary
retention, tachycardia, mydriasis (dilated
pupils) and agitation. Although physostigmine,
a reversible inhibitor of acteylcholinesterase,
is effective in treating symptoms, there is a
significant risk of cardiac toxicity (bradycardia,
AV conduction defects and asystole).

Mydriasis

[Q: 1270] MRCPass-Clinical
pharmacology

A 55 year old man of African origin presents
with blood pressure 210/100mmHg. Urinalysis
is negative and fundoscopy shows AV nipping.

Which of the following treatment options is
most appropriate?

1- Urgent admission for control of malignant
hypertension

2- Oral enalapril lOmg bd if hypertension
confirmed over 1-2 weeks

3- Oral atenolol 50mg od if hypertension
confirmed over 1-2 weeks

4- Oral nifedipine LA 30mg od if hypertension
confirmed over 1-2 weeks

Answer & Comments

Answer: 4- Oral nifedipine LA 30mg od if
hypertension confirmed over 1-2 weeks

The British Hypertension Society guidelines
suggest that the finding of blood pressure
200-219/110-119mmHg should be confirmed
with repeat measurements after 1-2 weeks,
then treated if still elevated.

Black patients have low renin hypertension,
therefore ACE inhibitors and (3-blockers as
single agents are less effective in this group.
Calcium channel blockers and diuretics are
effective agents. Nifedipine should be used as
a long-acting preparation, not a short acting
one.

[Q: 1271] MRCPass-Clinical
pharmacology

Clozapine is an atypical antipsychotic drug
that has fewer side effects than older
antipsychotics.

This is because of:

1- Decreased neurotransmitter release

2- Low affinity for 5HT receptors

3- Low affinity for dopamine D2 receptors

4- It does not cause agranulocytosis

5- There is better renal clearance

Answer & Comments

Answer: 3- Low affinity for dopamine D2
receptors

Clozapine has fewer extrapyramidal adverse
effects than older antipsychotics. This has
been attributed to its relatively low affinity for
D2 dopamine receptors. Unlike older
antipsychotics, clozapine has relatively high
affinity for 5HT receptors. Agranulocytosis is a
recognized complication of clozapine.

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[Q: 1272] MRCPass-Clinical
pharmacology

A 60 year old patient has recently been
commenced on digoxin.

Which of the following features is likely to
suggest digoxin toxicity?

1- Vomiting

2- Reverse tick in the lateral leads on ECG

3- Blindness

4- Chest pain

5- Supraventricular ectopics

Answer & Comments

Answer: 1- Vomiting

Digoxin toxicity can cause symptoms of
nausea and vomiting, xanthopsia (yellowness
in vision), dizziness, bradycardia and lethargy.
Reversed tick in the ST segments can be
associated with digoxin use and is not
necessarily a sign of toxicity.

[Q: 1273] MRCPass-Clinical
pharmacology

A 65 year old lady presents with transient loss
of vision which lasts half an hour. She has a
past medical history of hypertension. Her ECG
confirms atrial fibrillation.

Which one of the following therapy is most
appropriate?

1- Aspirin

2- Aspirin and dipyridamole

3- Aspirin and clopidogrel

4- Clopidogrel

5- Warfarin

Answer & Comments

Answer: 5- Warfarin

In a patient with previous TIA or CVA and
atrial fibrillation, warfarinisation must be

considered unless there are contraindications.
Using the CHADS-2 score, the patient scores 1
for a TIA, and 1 for Hypertension - a score of 2
and above suggests warfarin is appropriate.

A 35 year old lady has an aspirin overdose. She
is hyperventilating and complains of tinnitus.

What should be given?

1- N acetyl cysteine

2- Oil of wintergreen

3- Activated charcoal

4- Naloxone

5- Methylene blue

[Q: 1274] MRCPass-Clinical
pharmacology

Answer & Comments

Answer: 3- Activated charcoal

Initially after a salicylate overdose,
hyperventilation due to respiratory drive
stimulation causes a respiratory alkalosis. This
is followed by metabolic acidosis. Oil of
wintergreen contains salicylates. Management
includes repeated doses of activated charcoal
until plasma salicylate concentrations have
peaked.

[Q: 1275] MRCPass-Clinical
pharmacology

A 60 year woman has rheumatoid arthritis.
She states that she is allergic to Co-
trimoxazole.

Which of the following DMARDs should not be
used?

1- Gold

2- Penicillamine

3- Methotrexate

4- Sulfasalazine

5- Hydroxychloroquine

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Answer & Comments

Answer: 4- Sulfasalazine

Answer & Comments

Answer: 3- Ramipril

Co-trimoxazole is trimethoprim and
sulfamethoxazole. The patient is allergic to
sulphonamides.

[Q: 1276] MRCPass-Clinical
pharmacology

A 15 year old asthmatic patient who has been
given theophylline is now tachycardic with a
heart rate of 130 beats per minutes.

What is the mechanism of action of the drug?

1- Adenosine receptor antagonism

2- B1 receptor stimulation

In patients with reduced ejection fraction, ACE
- inhibitors have been shown to reduce
cardiovascular events (CVA and Ml) and
mortality. There are many trials with ACE-
inhibitors including SOLVD (enalapril), ISIS-4
(captopril) and HOPE (ramipril) trials.

[Q: 1278] MRCPass-Clinical
pharmacology

An 18 year old student is admitted with severe
crushing central chest pain with associated
nausea and profuse sweating. He admits to
smoking cocaine.

3- Alpha receptor agonist

4- Leukotriene inhibitor

5- Anticholinergic

Answer & Comments

Answer: 1- Adenosine receptor antagonism

Theophylline is a methylxanthine which is a
phosphodiesterase enzyme inhibitor. This
action increases cyclic AMP levels. It is also an
antagonist of adenosine receptors.

What is the mechanism of myocardial
ischaemia?

1- Coronary thrombosis

2- Tachycardia

3- Alpha receptor blockade

4- Coronary vasospasm

5- Parasympathetic activity

Answer & Comments

Answer: 4- Coronary vasospasm

[Q: 1277] MRCPass-Clinical
pharmacology

A 65 year old man has cardiac risk factors of
hypertension and is on aspirin.
Echocardiography shows reduced ejection
fraction at 50%.

Which one medication may reduce the risk of
future cardiovascular events?

1- Furosemide

2- Isosorbide mononitrate

3- Ramipril

4- Verapamil

5- Clopidogrel

Cocaine causes coronary vasospasm sufficient
to present as severe ischaemia.

Cocaine causes an increase in circulating
catecholamines. Therefore alpha-adrenergic
mediated focal or generalized coronary artery
spasm has been presumed to be the likely
mechanism to induce ischemia.

A 43 year old lady with known liver cirrhosis
has now been found to have a post prandial
glucose of 16 and had been high on two
previous occasions.

What drug should be commenced?

[Q: 1279] MRCPass-Clinical
pharmacology

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1- Preprandial insulin

2- Metformin

3- Rosiglitazone

4- Gliclazide

5- Acarbose

Answer & Comments

Answer: 4- Gliclazide

Type 2 diabetes in liver cirrhotic patients
respond well to sulfonylureas which enhance
peripheral tissue sensitivity to insulin. This
should be considered first and insulin
subsequently added when glycaemic control is
not achieved.

colestyramine). Ezetimibe is currently licensed
for use in combination with a statin in patients
who fail to reach desired lipid profiles or as
monotherapy in patients intolerant to a statin.

[Q: 1281] MRCPass-Clinical
pharmacology

Frusemide (furosemide) acts on which part of
the kidney?

1- Bowman's capsule

2- Ascending loop of Henle

3- Descending loop of Henle

4- Distal convoluted tubule

5- Proximal convoluted tubule

[ Q: 1280 ] MRCPass - Clinical
% pharmacology

A 60 year old man with elevated cholesterol
has failed to reach a desired cholesterol level
on statin treatment.

The endocrinologist suggests ezetimibe.

Which of the following is on effect of
ezetimibe?

1- Elevation in plasma triglyceride

2- Decreased absorption of fat soluble
vitamins

3- Reduction in high density lipoprotein (HDL)

4- Reduction in low-density lipoprotein (LDL)

5- Prevents cholesterol synthesis

Answer & Comments

Answer: 4- Reduction in low-density

lipoprotein (LDL)

Ezetimibe acts by prevent cholesterol
absorption from the small intestine. Typically
it reduces LDL-cholesterol by approximately
20%, triglycerides by up to 5% and raises HDL-
cholesterol by approximately 5%. It does not
inhibit the absorption of fat-soluble vitamins
unlike the anionexchange resins (e.g.

Answer & Comments

Answer: 2- Ascending loop of Henle

Frusemide acts on the thick portion of the
ascending loop of Henle.lt inhibits Na+ and Cl-
reabsorption there via Na+, K+, -ATPase-
dependent pump. Owing to the large NaCI
absorptive capacity of the loop of Henle,
agents that act at this site produce a diuretic
effect much greater than that seen with other
diuretic groups.

A 25 year old lady has with multiple sclerosis is
considered for (3-interferon by her neurologist.
She has relapsing episodes of decreasing
mobility and bladder dysfunction.

When is beta interferon recommended?

1- First onset of the disease

2- When there is urinary incontinence

3- Chronic progressive multiple sclerosis

4- Relapsing remitting multiple sclerosis

5- During a relapse

[ Q: 1282 ] MRCPass - Clinical
pharmacology

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Answer & Comments

Answer: 4- Relapsing remitting multiple
sclerosis

sodium 137 mmol/l
potassium 4.3 mmol/l
urea 25 mmol/l

(3-interferon is not commenced during the first
event seen. It is a long term treatment (as
opposed to steroids for acute relapses) which
is of benefit only in the relapsing remitting
form (about 40% of MS patients have this
form), and slows progression of disability and
reduces demyelinating lesions.

^ Q: 1283 ] MRCPass - Clinical

Z pharmacology

I KaB99S9 _ ss _ 9 ^

A 50 year old lady is given methotrexate for
severe rheumatoid disease causing joint pains
and functional limitation. She also has to be
given folinic rescue therapy.

What is the mechanism by which
methotrexate acts?

1- Increasing folic acid excretion

2- DNA binding

3- Binding to dihydrofolate reductase

4- Increasing nucleotide synthesis

5- Inhibiting DNA gyrase

Answer & Comments

Answer: 3- Binding to dihydrofolate reductase

creatinine 360 pmol/l
Creatine Kinase 11,000 U/l
What is the diagnosis?

1- Alcohol intoxication

2- Tricyclic antidepressant overdose

3- Methaemoglobinaemia

4- Rhabdomyolysis

5- Cocaine overdose

Answer & Comments

Answer: 4- Rhabdomyolysis

The likely diagnosis is ethylene glycol
poisoning, the clue being the alcohol smell.
There are many causes of rhabdomyolysis,
such as trauma and burns, sepsis and drug
oversose.

[Q: 1285] MRCPass-Clinical
pharmacology

A 40 year old lady is being considered for
treatment for rheumatoid arthritis.

Which of the following is a disease modifying
anti rheumatic drug?

Binding of methotrexate to dihydrofolate
reductase reduces nucleotide synthesis as well
as amino acids serine and methionine. Folinic
acid rescue is usually given after methotrexate
therapy (e.g. 24 hours) to reduce

myelosuppression side effects.

1- Mercury

2- Phenylephrine

3- Silver

4- Sulfasalazine

5- Benzoyl peroxide

[Q: 1284] MRCPass-Clinical
pharmacology

A 46 year old patient was found unconscious
by a friend and brought to hospital. On
examination he smelled of alcohol and had a
GCS of 5/15.

Investigations showed:

Answer & Comments

Answer: 4- Sulfasalazine

DMARDS include gold, choloroquine,
sulfasalazine, penicillimine, methotrexate,
azathioprine and leflunomide.

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[Q: 1286] MRCPass-Clinical
pharmacology

Which one of following drugs works by
inhibiting tumour necrosis factor?

1- Cyclosporin

2- Methotrexate

3- Montelukast

4- Infliximab

5- Mesalazine

Answer & Comments

Answer: 4- Infliximab

Etanercept and infliximab inhibit TNF. They
are licensed in the treatment of rheumatoid
arthritis.

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[ Q: 1287 ] MRCPass - Cardiology

A 60 year man who is type 2 diabetic
is admitted with chest pain. His ECGs show
inferior ST elevation of 1 mm in 2 leads. He is
thrombolysed with steptokinase. His BM
measurement is 15, and has missed his
gliclazide dose today.

What is the best management?

1- Continue with gliclazide

1- Restrictive cardiomyopathy

2- Dilated cardiomyopathy

3- Constrictive pericarditis

4- Ischaemic cardiomyopathy

5- Pulmonary embolus

Answer & Comments

Answer: 1- Restrictive cardiomyopathy

2- PRN actrapid to keep the BMs controlled

3- Iv sliding scale insulin

4- Commence metformin

5- Ignore the BMs and focus on his cardiac
side

Answer & Comments

Answer: 3- Iv sliding scale insulin

The DIGAMI study compared "conventional"
anti-diabetic therapy to intensive insulin
therapy consisting of acute insulin infusion
during the early hours of Ml and thrice-daily
subcutaneous insulin injection for the
remainder of the hospital stay and a minimum
of 3 months thereafter. For patients with
insulin and better glycaemic control, mortality
of patients were decreased at one year.

[ Q: 1288 ] MRCPass - Cardiology

A 55 year old patient presented with
breathlessness and ankle oedema. The blood
pressure is 135/80 mmHg. On examination,
her JVP rises with inspiration. She has a soft
systolic murmur and a third heart sound.

Blood tests reveal a Hb 10.5 g/dl, WCC 7.5 x
10 9 /L, Platelets 150 x 10 9 /L, sodium 136
mmol/I, potassium 3.5 mmol/I, creatinine 140
pmol/l, urea 6 pmol/l.

ECG shows poor R wave progression. An
echocardiogram shows no pericardial effusion,
the ventricles are stiff and systolic function is
mildly impaired.

Which of the following is the likely diagnosis?

In this scenario, the symptoms can be caused
by any form of cardiomyopathy. The rise in
JVP with inspiration suggests either
constrictive or restrictive cardiomyopathy.

Echocardiography showing no pericardial
effusion and stiffness suggests restrictive
rather than constrictive cardiomyopathy. The
transmitral dopplers on the echo may show
E/A wave reversal and high velocities which
may suggest restrictive picture.

This may be due to infiltration due to
haemochromatosis, endomyocardial fibrosis,
sarcoidosis, myeloma, lymphoma or
connective tissue disease.

[ Q: 1289 ] MRCPass - Cardiology

A 40 year old patient had a mitral
valve replacement for mitral stenosis 1 month
ago. She presents with fevers, lethargy and
rigor.

Her blood tests reveal Hb 9.5 g/dl, WCC 13 x
10 9 /L, platelets 500 x 10 9 /L, sodium 136
mmol/I, potassium 4.2 mmol/l, ESR 90 mm/hr,
CRP 180 mg/I.

She also has 2 splinter haemorrhages and 2+
of blood on urine dipstick. 3 sets of blood
cultures are taken.

Which of the following organisms is most likely
to be grown in the blood cultures?

1- E coli

2- Listeria monocytogenes

3- (3 haemolytic Group A streptococcus

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4- Klebsiella

5- Staphylococcus epidermidis

Answer & Comments

Answer: 5- Staphylococcus epidermidis

In a patient with prosthetic valve, causes can
be divided into early (within 60 days of
surgery) and late stages.

Early prosthetic valve endocarditis is usually
the result of perioperative contamination.
Causative organisms include Staphylococcus
epidermidis (30%), Staphylococcus aureus
(20%), and gram-negative aerobes (20%).

The two best options are carvedilol and
spironolactone. Both B blocker trials (CIBIS II,
Merit HF, Copernicus) and spironolactone
trials (RALES) have shown symptomatic
improvement and decreased mortality.

In this patient with little signs of fluid
overload, a beta blocker can be started first,
and then spironolactone added as well.

[ Q: 1291 ] MRCPass - Cardiology

A 55 year old man has progressive
shortness of breath and ankle oedema. He has
come from Africa originally and gives a history
of probably tuberculosis many years ago.

Late prosthetic valve endocarditis is usually
the result of bacteremia from dental or
genitourinary sources, Gl surgery, or
intravenous drug abuse. The causative
organisms are similar to those causing native
valve endocarditis. These include
Streptococcus viridans (30%), S epidermidis
(30%) and S aureus (12%).

^ [ Q: 1290 ] MRCPass - Cardiology

/ ---- “

# A 65 year old lady has ischaemic
cardiomyopathy and symptoms of
breathlessness walking up one flight of steps.
Her breath sounds are clear. Chest X ray
shows cardiomegaly and clear lung fields. She
is currently on frusemide 40mg bd and
perindopril 4 mg at night.

Whot medication should be added?

1- Spironolactone

2- Carvedilol

3- Digoxin

4- Amiodarone

On examination, he has a blood pressure of
105/55 mmHg, raised JVP +6 cm with a rapid y
descent and significant ankle oedema.

What is the likely diagnosis?

1- Cardiac tamponade

2- Aortic regurgitation

3- Restrictive cardiomyopathy

4- Pericardial constriction

5- Left ventricular impairment causing heart
failure

Answer & Comments

Answer: 4- Pericardial constriction

The signs of pericardial constriction /
constrictive pericarditis are rapid y descent,
raised JVP and Kussmaul's sign.

The y descent is often blunted in cardiac
tamponade. A further clue is the history of
tuberculosis which predisposes to constrictive
pericarditis.

5- Diltiazem

Answer & Comments

Answer: 2- Carvedilol

[ Q: 1292 ] MRCPass - Cardiology

A 75 year old man has become
progressively more breathless. On
examination he has a displaced cardiac apex
and a third heart sound. Chest XR confirms
cardiomegaly. An echocardiogram shows Left

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ventricle size of 6.5 cm (<6cm) and LV ejection
fraction of 25%.He is on Frusemide,
Perindopril and spironolactone.

Which of the following drugs should be added
to his current therapy?

1- Diltiazem

2- Verapamil

3- Atorvastatin

4- Ezetemide

5- Bisoprolol

Answer & Comments

Answer: 5- Bisoprolol

The CIBIS trial showed that bisoprolol showed
improvement in functional status and reduced
hospitalisation. Mortality however, was not
decreased on bisoprolol in this trial. There are
other trials which have shown a small
mortality benefit for beta blockers in heart
failure. Other B blockers which can be used
are metoprolol (MERIT HF study) and
carvedilol.

[ Q: 1293 ] MRCPass - Cardiology

A 50 year old man has suffered an
uncomplicated myocardial infarct 3 days ago
and at the moment he has no problems. He is
a tourist and wishes to travel back home as
soon as possible.

How soon after an uncomplicated myocardial
infarct may a patient travel by flight safely?

1- 3 days

2- 14 days

3- 4 weeks

4- 2 months

5- 3 months

Answer & Comments

Answer: 2-14 days

A patient should be fit to fly 14 days after an
uncomplicated myocardial infarct, after
normal activities have been resumed. For
complicated Mis, the patient has to w ait until
symptoms stabilise. Coronary artery bypass
graft and other chest surgery - recommended
wait about 2 weeks so that any air introduced
into chest will have become absorbed.

[ Q: 1294 ] MRCPass - Cardiology

A 65 year old man has an angioplasty
to the left anterior descending artery.

In considering medical therapy , which of the
following reduces restenosis rates following
angioplasty?

1- Angiotensin converting enzyme inhibitors

2- Abciximab

3- Beta blockers

4- Low-molecular weight heparin

5- Pravastatin

Answer & Comments

Answer: 2- Abciximab

There is some data to suggest that the use of
the anti-platelet glycoprotein llb/llla receptor
blocker (abciximab) may reduce the risk or re¬
stenosis in both diabetic and non-diabetic
patients.

[ Q: 1295 ] MRCPass - Cardiology

A 50 year old man presents with
palpitations. His ECG shows AV dissociation.

Which of the following conditions is most likely
to cause AV dissociation on an ECG?

1- 1st degree AV block

2- Atrial flutter

3- Mobitz type II block

4- Wenkebach

5- Complete heart block

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Answer & Comments

Answer: 5- Complete heart block

Answer & Comments

Answer: 2- Troponin T

Complete (3rd degree) heart block and
ventricular tachycardia are most likely to
cause AV dissociation on an ECG.

[ Q: 1296 ] MRCPass - Cardiology

A 60 year old man has palpitations.
An admission ECG shows QTc prolongation of
0.48 s.

Which of the following conditions might be
associated?

1- Digitalis

2- Hyponatraemia

3- Hyperthermia

4- Hypocalcaemia

5- Hyperkalaemia

Answer & Comments

Answer: 4- Hypocalcaemia

Hypokalaemia, hypocalcaemia ,

hypomagnesaemia and hypothermia can
cause prolonged QT interval on the ECG.
Prolonged QT is classified as a QTc interval
(corrected) of more than 0.44 seconds.

[ Q: 1297 ] MRCPass - Cardiology

A 45 year old man has chest pain
walking up hills.

Which of the following investigations is the
best for risk stratification of angina?

1- ECG

2- Troponin T

3- Echocardiogram

4- Coronary angiogram

5- Thallium myocardial perfusion scan

The high risk factors are positive troponin and
dynamic ST depression on ECG with angina.

Those in the high risk group should be
referred for urgent coronary angiography.

[ Q: 1298 ] MRCPass - Cardiology

A 65 year old man has palpitations.
He has a broad complex tachycardia on the
ECG. In a broad complex tachycardia.

Which of the following would be the strongest
indication towards a diagnosis of VT?

1- Discordant QRS complexes in the chest
leads

2- Extreme right axis deviation

3- Hemodynamic instability

4- Trifascicular block on ECG

5- Cannon a waves

Answer & Comments

Answer: 5- Cannon a waves

Any evidence of AV dissociation such as
cannon a waves effectively rules out a
supraventricular tachycardia. Features
suggestive of VT, rather than SVT with bundle
branch block are:

■ cannon a waves on JVP

■ fusion and/or capture beats

■ Left axis deviation

QRS duration > 140 msec
concordance of the QRS complexes in
the chest leads

history of ischaemic heart disease

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[ Q: 1299 ] MRCPass - Cardiology

A 20 year old university student
complains of palpitations which last 10
minutes and are irregular. He has had three
episodes over the past year and has come to
outpatients to be assessed. He is aware of the
palpitations but does not feel unwell. His ECG
shows delta waves.

What should be the next course of action?

1- Discharge and no further investigation

2- Routine referral to a cardiologist

3- He is high risk and needs admission into
hospital

4- Routine DC cardioversion

5- Anticoagulation

Answer & Comments

Answer: 2- Routine referral to a cardiologist

He is in sinus rhythm at the moment. The
delta waves and short PR interval suggests
Wolff Parkinson White syndrome. He needs a
referral to a cardiologist to discuss ablation of
accessory pathway, and should have a 24 hour
tape and echocardiogram.

2- Aspirin

3- Warfarin

4- DC cardioversion

5- Atenolol

Answer & Comments

Answer: 3- Warfarin

The patient's heart rate is not fast. She scores
2 on the CHADS -65 score (she is above age 65
and she has hypertension) there is a
significant benefit in formal anticoagulation
with w arfarin in view of the risk of
thromboembolism

^ [ Q: 1301 ] MRCPass - Cardiology

0 A 30 year old patient complains of
dizzy spells. Upon admission, he has an ECG
which shows a PR interval of 0.6s and QT
interval of 0.5s.

Which one of the following medications could
be responsible?

1- Aspirin

2- Amoxycillin

3- Terfenadine

4- Digoxin

5- Acetazolamide

Answer & Comments

Answer: 3- Terfenadine

Short PR interval and delta waves

[ Q: 1300 ] MRCPass - Cardiology

A 75 lady was found to have Atrial
Fibrillation on her ECG. She has a history of
hypertension. The rate was 85 min and BP was
140/85 mmHg.

What management should be considered
next?

1- Digoxin

A QT interval of >0.45 is prolonged. Common
drugs are tricyclic antidepressants (eg.
amitryptiline), quinidine, erythromycin,
amiodarone, phenothiazines

(chlorpropramide), antihistamines

(terfenadine) and grapefruit juice.

[ Q: 1302 ] MRCPass - Cardiology

A 65 year old man with diabetes
mellitus has a blood pressure of 190/90
mmHg. Clinical examination was normal.

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An ECG reveals evidence of left ventricular
hypertrophy.

Which one of the following drugs appropriate
treatment for hypertension?

1- Sodium nitroprusside

2- Labetalol

3- Atenolol

4- Doxazosin

5- Bendrofluazide

Answer & Comments

Answer: 5- Bendrofluazide

The British Hypertensive Society guidelines
would suggest either a Diuretic or Calcium
channel blocker [C or D for older or black
patient]. Although ACE inhibitor is
recommended for diabetic patients, this is not
among the options, hence the best choice is
the diuretic (D).

[ Q: 1303 ] MRCPass - Cardiology

A 40 year old lady noticed transient
loss of vision and presented for assessment.
She has had fevers for 3 months,
breathlessness and orthopnoea. Her CRP and
ESR are elevated. On examination, she is
clubbed. She has a loud first heart sound and a
mid diastolic murmur.

What is the diagnosis?

1- Mitral stenosis

2- ASD

3- Left ventricular aneurysm

4- Left atrial appendage thrombus

5- Atrial myxoma

Answer & Comments

Answer: 5- Atrial myxoma

An atrial myxoma can present with fevers,
raised inflammatory markers and
breathlessness worst lying down. There may

be embolic causes of CVA or TIA. The murmur
could be a diastolic 'plop 1 or there may be
clinical signs similar to mitral stenosis.

Atrial Myxoma

[ Q: 1304 ] MRCPass - Cardiology

A 35 year old woman presented with
a history of intermittent light-headedness.
Clinical examination and 12-lead ECG were
normal.

Which of the following, if present on a 24 hour
Ho Iter ECG tracing , would be the most
clinically important?

1- Atrial premature beats

2- Profound sleep-associated bradycardia

3- Supraventricular tachycardia

4- Transient Mobitz type 1 atrioventricular
block

5- Ventricular premature beats

Answer & Comments

Answer: 3- Supraventricular tachycardia

Mobitz type 1 is Wenkebach and does not
usually cause symptoms. The most likely
arrhythmia which needs treating e.g. with a
beta blocker, is SVT.

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; j/ J; b |/J;- /

wfff 1^44444

r'rTTTTt^^rrrrr|

^TTTTTTTTTTTTTTT^

SVT

Which of the following is the most likely
diagnosis?

1- Myocardial infarction

2- Pericarditis

3- Myocarditis

4- Pulmonary emboli

5- Pericardial effusion

\fi

[ Q: 1305 ] MRCPass - Cardiology

Answer & Comments

• ll

A 50 year old woman with previous

Answer: 3- Mvocarditis

rheumatic heart disease has been lost to
follow up for some time. She now has
symptoms of breathlessness. On examination,
she has a tapping apex beat, diastolic murmur
and a large V wave in the JVP.

What is the likely diagnosis?

1- Isolated mitral stenosis

2- Mixed mitral valve disease

3- Mitral stenosis and tricuspid regurgitation

4- Cardiac tamponade

5- Aortic regurgitation

Answer & Comments

Answer: 3- Mitral stenosis and tricuspid
regurgitation

Rheumatic fever has predisposed the patient
tow ards mitral stenosis, which would
manifest as signs of a low rumbling diastolic
murmur and a tapping apex beat. The large V
wave in the JVP suggests tricuspid
regurgitation which is secondary to pulmonary
hypertension (also may have a loud second
heart sound and a right ventricular heave).

(

[ Q: 1306 ] MRCPass - Cardiology

A 33 year old man presents with
chest pains and fatigue for several days.

His observations show a temperature of 38°C,
pulse 100 bpm, BP 100/70 mmHg. ECG shows
T wave inversion in the anterior and inferior
leads. The troponin I is 3 ng/mL (<0.04).

Pyrexia, chest pain (pleuritic), raised troponin,
T wave changes on the ECG would be
suggestive of myocarditis.

Pericarditis usually causes saddle shaped ST
elevation on ECG. Coxsackie B is the
commonest cause. Other causes are HIV,
diphtheria, Chagas disease, Lyme disease, SLE
and arsenic poisoning.

[ Q: 1307 ] MRCPass - Cardiology

A 20 year old lady is short in stature
for her age. She has a webbed neck and
oligomenorrhoea. On physical examination,
she a continuous murmur heard over both
front of the chest as well as her back. A chest
radiograph reveals a prominent left heart
border and rib notching.

Which of the following lesions best explains
these findings?

1- Thoracic aortic aneurysm

2- Single large atrioventricular valve

3- Supravalvular narrowing in aortic root

4- Coarctation of the aorta

5- Shortening and thickening of chordae
tendineae of mitral valve

Answer & Comments

Answer : 4- Coarctation of the aorta

Coarctation of the aorta is the most likely
diagnosis in this patient with Turner's

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syndrome. Rib notching on the chest X ray is a
big clue. The underlying abnormality is a
deformity of the aortic media that causes
eccentric narrow ing of the lumen.

Rib Notching in Coarctation of the aorta (ribs
4-8 bilaterally). This occurs due to collateral

vessel formation.

[ Q: 1308 ] MRCPass - Cardiology

A 40 year old man presented
because he is concerned about his family
history of hypertrophic obstructive
cardiomyopathy. His brother has recently
deceased from due to the condition.

What investigation should be offered?

1- Transthoracic echocardiogram

2- Transoesophageal echocardiogram

3- Electrophysiological study

4- Coronary angiogram

5- Cardiac thallium scan

echocardiogram, and beyond that genetic
testing may be helpful.

[ Q: 1309 ] MRCPass - Cardiology

A 42 year woman who has received
radioactive iodine many years ago has routine
blood tests. She does not have any symptoms
suggestive of angina.

Her results reveal:

Free Thyroxine 10.2 pmol/l (9.8-23)
TSH 13 mU/l (0.5-4.5 mU/l)

Total cholesterol 7.8 mmol/l (<5 mmol/I)

Plasma triglycerides 2.5 mmol/l (<2 mmol/l)

What is the appropriate treatment for the
elevated lipid status?

1- Diet control

2- Simvastatin

3- Thyroxine replacement

4- Cholestyramine

5- Clofibrate

Answer & Comments

Answer: 3- Thyroxine replacement

Medical conditions associated with
hypothyroidism include anemia, dilutional
hyponatremia, and hyperlipidemia. Subclinical
hypothyroidism (as demonstrated in this case)
is usually indicated by a serum TSH level betw
een the upper limit of normal (about 5 mll/L)
and 15 mLI/L; occasionally the level may be
higher. The serum free T4 level is, by
definition, within the normal range.
Treatment of choice is T4 replacement with
levothyroxine sodium.

Answer & Comments

Answer: 1- Transthoracic echocardiogram

Relatives of patients with HOCM should be
offered screening especially in the context of a
fatality. The best form is transthoracic

[ Q: 1310 ] MRCPass - Cardiology

A 65 year old man has symptoms of
breathlessness and chest pains. He has cardiac
risk factors of smoking and elevated
cholesterol. On examination, he has a harsh
systolic murmur and quiet second heart sound

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consistent with aortic stenosis.
Echocardiography reveals a gradient of 75
mmHg across the aortic valve.

Which of the following is the most useful
investigation?

1- Transoesophageal echocardiography

2- Coronary angiography

3- Right heart cardiac catheter

4- Cardiac electrophysiological study

5- CT pulmonary angiogram

Answer & Comments

Answer: 2- Coronary angiography

The diagnosis is severe aortic stenosis with
significant clinical symptoms. The patient is
likely to require surgical aortic valve
replacement. Along with the risk factors, there
is high risk of coronary artery disease.
Coronary angiography should be the next
investigation to investigate w hether coronary
bypass grafts are necessary as well.

[ Q: 1311 ] MRCPass - Cardiology

A 65 year old man had a myocardial
infarction 2 months ago. He has had a stent
placed in the LAD artery following angioplasy.
During a routine follow up Exercise Test he
has a 15 beat run of nonsustained VT. The
nonsustained VT occurred halfway through
Stage 2.

Whot is the next definitive investigation?

1- Thallium scan

2- Cardiac electrophysiological study

3- Echocardiogram

Post Ml VT is most commonly due ventricular
scar tissue. This patient has had coronary
revascularisation and still has significant runs
of VT. Hence an electrophysiological study to
attempt to stimulate VT is necessary. If the
study demonstrated VT, then the patient
should have an defibrillator (ICD) inserted
[MADIT trial, AmJCardiol 1997;79:167].

[ Q: 1312 ] MRCPass - Cardiology

A 55 year old man has palpitations
and broad complex tachycardia on the ECG.

In a broad complex tachycardia, which of the
following suggests a diagnosis of supra¬
ventricular tachycardia (SVT)?

1- Cannon a waves

2- Termination with adenosine

3- QRS duration >140msec

4- Fusion beats

5- Concordance of V leads

Answer & Comments

Answer: 2- Termination with adenosine

Features which favour of VT include:

evidence of AV dissociation (cannon a waves
on JVP)

fusion and/or capture beats

left axis deviation (betw een 90 and 180
degree)

QRS duration > 140 msec
concordance of V leads (monophasic QRS)
Features which favor of SVT:

4- 24 hour tape recording

5- Repeat coronary angiography

Answer & Comments

Answer: 2- Cardiac electrophysiological study

Long-short cycle sequence

Slow ing or termination by increasing vagal
tone or with adenosine

Trileafed QRS in VI

RP interval < 100 msec

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[ Q: 1313 ] MRCPass - Cardiology

A 70 year old man has a history of
progressive tiredness and breathlessness. On
examination there is pallor, his pulse rate is 65
beats per minute, and is slow rising in nature.
The JVP is not elevated.

His apex beat is at the 5th left intercostal
space mid-clavicular line and it is heaving in
nature. There is a systolic thrill in the right
sternal edge and there is a systolic murmur in
the aortic area radiating to the neck.

Investigations reveal:

Hb 8.0 g/dl

MCV 70 fL.

Upon further investigation of this patient's
anaemia the most useful test would be:

1- Capsule endoscopy

2- Barium swallow

3- Colonoscopy

4- CT pneumocolon

5- Flexible sigmoidoscopy

Answer & Comments

Answer: 3- Colonoscopy

The patient has features of aortic stenosis and
iron deficiency anaemia. Aortic stenosis may
be associated with angiodysplasia of the colon
and the best test to elucidate this is
colonoscopy.

[ Q: 1314 ] MRCPass - Cardiology

A 25 year man presents with
episodes lightheadedness. He has no
significant past medical history. Cardiac
examination reveals no heart murmurs, chest
X-ray and ECG are normal. A 24 hour tape is
requested.

Which arrhythmia might cause his symptoms?

1- Atrial extrasystole

2- Supraventricular tachycardia

3- Wenkebach

4- Ventricular extrasystole

5- First degree heart block

Answer & Comments

Answer: 2- Supraventricular tachycardia

Out of the following options, the most likely
rhythm which may cause symptoms are
supraventricular tachycardia. The other
rhythms may cause palpitations but would be
unusual to cause light headedness /
presyncope.

wJHjJI

^rrrT M rrf^rt^rrrr j/; -

Supraventricular tachycardia

[ Q: 1315 ] MRCPass - Cardiology

A 50 year old man presents with
broad complex tachycardia. He has a BP of
100/70 and a pulse rate of 170. The duty
medical registrar is considering administration
of antiarrhythmics.

Which one of the following medications is
contraindicated in this patient?

1- Magnesium

2- Amiodarone

3- Verapamil

4- Procainamide

5- Lignocaine

Answer & Comments

Answer: 3- Verapamil

The patient is likely to have ventricular
tachycardia in view of the very fast rate and
broad complexes. All are useful agents which

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can be used in conjunction cautiously for VT
except for Verapamil.

Verapamil is contraindicated in VT because it
can cause the blood pressure to drop
drastically due to negative ionotropic action.

[ Q: 1316 ] MRCPass - Cardiology

# A 65 year old man has a systolic
murmur in the aortic area.

In assessing him , which of the following is a
clinical feature of severe aortic stenosis?

1- Loud murmur

2- Slow rising pulse

3- Enlarged left atrium

4- Palpable apex beat

5- Early diastolic murmur

2- ACE inhibitor, (3 blockers, aldosterone
antagonist

3- ACE inhibitor, loop diuretic

4- (3 blockers, angiotensin II blocker

5- ACE inhibitor, (3 blockers, statin

Answer & Comments

Answer: 2- ACE inhibitor, (3 blockers,
aldosterone antagonist

Of all the combinations, ACE inhibitor /
angiotensin II blocker with (3 blockers and
aldosterone antagonist (spironolactone,
eplerenone) is the most appropriate given the
fact that this patient has symptomatic heart
failure. Trials have shown that these
medications have a mortality and also
symptomatic benefit.

Answer & Comments

[ Q: 1318 ] MRCPass - Cardiology

Answer: 2- Slow rising pulse

A 45 year old Caucasian man has

The clinical signs consistent with severe aortic
stenosis are:

Slow rising pulse character

hypertension. He has a blood pressure
consistently above 160/90 mmHg. He does
not have signs of malignant hypertension or
renal failure.

4th heart sound

Soft aortic 2nd heart sound

Which of the following is the most appropriate
antihypertensive?

1- Diltiazem

Systolic thrill

2- Methyldopa

Extended length of murmur in systole

3- Sodium nitroprusside

[ Q: 1317 ] MRCPass - Cardiology

A 60 year old man has had previous
myocardial infarction. He has symptoms of
breathlessness consistent with NYHA class III
heart failure. Echocardiography shows an LV
ejection fraction of 35%.

Which of the following combinations of
medication is most appropriate?

1- ACE inhibitor, (3 blockers, angiotensin II
blocker

4- Lisinopril

5- Bendrofluazide

Answer & Comments

Answer: 4- Lisinopril

According to the British Hypertension Society
guidelines, a patient who is non-black and
under 55 years of age should be considered
for an ACE inhibitor or Beta blocker. In this
case the ACE-I lisinopril is the best choice.

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[ Q: 1319 ] MRCPass - Cardiology

A 32 year old lady complains of
periodic episodes of palpitations and light¬
headedness for about 20-30 minutes. It
occurred once a week for the last few weeks.
An ECG showed normal sinus rhythm.

What is the investigation of choice?

1- 24 hr holter monitoring

2- Echo

3- Exercise tests

4- Patient controlled Loop recorder

5- Electrophysiological study

Answer & Comments

Answer: 4- Patient controlled Loop recorder

The frequency of the symptoms is low , hence
a 24 hour tape may not capture an
arrhythmia. A patient controlled loop recorder
allows recording of rhythms around the time
of the event, hence a much higher likelihood
of recording an abnormal rhythm.

[ Q: 1320 ] MRCPass - Cardiology

A 61 year old man with a previous
history of myocardial infarction, presents with
recurrent loss of consciousness. On
examination there were signs of left
ventricular aneurysm. BP was 110/70 mmHg
and pulse rate was 90/min. CT head was
normal.

What is the cause of loss of consciousness?

1- Vasovagal syncope

2- Pulmonary embolism

3- Stroke

4- Ventricular tachycardia

5- Hypersensitive carotid syndrome

Answer & Comments

Answer: 4- Ventricular tachycardia

A patient with ischaemic heart disease and
ventricular aneurysm is at high risk of
developing ventricular arrhythmias. This can
certainly lead to the loss of consciousness.

[ Q: 1321 ] MRCPass - Cardiology

A 50 year old man has reversed
splitting of the second heart sound on
examination.

Which of the following conditions is this seen
in?

1- Atrial septal defect

2- Pulmonary regurgitatoin

3- Mild aortic stenosis

4- Left bundle branch block

5- Ventricular septal defect

Answer & Comments

Answer: 4- Left bundle branch block

Reversed splitting occurs with reversal of the
normal A2 - P2 pattern. Thus A2 may be
delayed as with severe aortic stenosis, and left
bundle branch block (LBBB). P2 may also be
early with Wolff-Parkinson-White type B and
Persistent ductus arteriosus. Atrial septal
defects show wide fixed splitting, and right
bundle branch block (RBBB) has wide splitting.

[ Q: 1322 ] MRCPass - Cardiology

With regard to the conducting
system of the heart , where are the Purkinje
fibres situated?

1- At the superior portion of the myocardium

2- In the middle of the myocardium

3- Subendocardial

4- Transmural

5- Subepicardial

Answer & Comments

Answer: 3- Subendocardial

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The Purkinje fibres run in a subendocardial
position. This results in depolarisation of the
heart from the endocardium to the
epicardium.

[ Q: 1323 ] MRCPass - Cardiology

A 40 year old lady has a pulmonary
systolic murmur which is louder on
inspiration. She also has a right ventricular
heave. The second heart sound is wide and
fixed with splitting.

What is the most likely diagnosis?

1- Tricuspid atresia

2- Patent ductus arteriosus

3- Atrial septal defect

4- Aortic stenosis

5- Mitral stenosis

[ Q: 1324 ] MRCPass - Cardiology

A 25 year old man presents with a
collapse w hilst running for the bus. He has no
previous known past medical history. An ECG
done on admission to the hospital fulfils the
criteria for LVH. On examination, he has a
jerky pulse and prominent apex beat. There is
a systolic murmur heard in the aortic area.

What is the likely diagnosis?

1- Dilated cardiomyopathy

2- Hypertrophic cardiomyopathy

3- Ischaemic cardiomyopathy

4- Restrictive cardiomyopathy

5- Haemochromatosis

Answer & Comments

Answer: 2- Hypertrophic cardiomyopathy

Answer & Comments

Answer: 3- Atrial septal defect

With atrial septal defect (ASD), a Primum
defect causes RBBB and LAD, w hilst
Secundum causes RBBB and RAD on the ECG.
Secundum ASD is associated with Holt-Oram
syndrome (tri-phalangeal thumb and radial
abnormalities). A systolic murmur is heard in
the pulmonary area because of increased
pulmonary valve flow due to pulmonary
hypertension. Similarly, a left parasternal
heave is present due to RVH.

F ntargad Right Ventode
SECUNDUM ATRIAL SEPTAJL DEFECT

Hypertrophic cardiomyopathy which is
familial, can present with presyncopal
episodes as described above. Over a hundred
different mutations in at least nine different
genes, all encoding sarcomeric polypeptides,
have been associated with hypertrophic
cardiomyopathy (HCM). LVH changes with
strain pattern and prominent q waves are
common on the ECG. A prominent, jerky pulse
is a clue.

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[ Q: 1325 ] MRCPass - Cardiology

A 50 year old man who had an
angioplasty asks about Clopidogrel.

What is Clopidogrel's mode of action?

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1- ADP receptor antagonist

2- Affects APTT

3- Inhibits cyclooxygenase

4- Hydroxymethyl Coenzyme A inhibitor

5- Glycoprotein 11 b/Ilia inhibitor

Answer & Comments

Answer: 1- ADP receptor antagonist

Clopidogrel prevents platelet aggregation
through antagonism of the ADP receptor on
platelets.

[ Q: 1326 ] MRCPass - Cardiology

A 55 year old man with
breathlessness presents to A&E. On
examination, he has an inspiratory systolic fall
in arterial pressure of lOmmHg.

Which one of the following is most likely to be
ossocioted?

1- Myocardial infarction

2- Pulmonary stenosis

3- Cardiac tamponade

4- Pneumonia

5- Myocarditis

Answer & Comments

Answer: 3- Cardiac tamponade

Pulsus paradoxus is most commonly related to
cardiac tamponade. The y descent (diastolic)
phase is absent in tamponade. Pulsus
paradoxus is defined as an inspiratory systolic
fall in arterial pressure of lOmmHg. It not only
occurs in cardiac tamponade, but also in
massive PE, severe COPD and
hypotension/shock.

What is the ECG likely to show now ?

1- Prominent p waves

2- Delta waves

3- ST depression

4- Prolonged PR interval

5- LBBB

Answer & Comments

Answer: 5- LBBB

Permanent pacing can be single chamber
atrial (e.g. AAI), single chamber ventricular
(e.g. VVI) or dual chamber (e.g. DDD). A VVI
pacemaker would mean that the pacing lead is
placed in the right ventricle, causing a LBBB
pattern.

[ Q: 1328 ] MRCPass - Cardiology

A 27 year old man presents with
lethargy, poor exercise tolerance and weight
loss. On examination he looks very slim and
has a pulse rate of 120 beats per minute
regular. The pulse volume decreases during
inspiration.

His JVP is elevated 5 cms and the level
increases during inspiration. On auscultation
of the heart sounds an early diastolic sound is
audible at the left sternal edge. On
examination of the abdomen there is 4
fingerbreadths of hepatomegaly and ascites.

What is the diagnosis?

1- Mitral valve prolapse

2- Mitral stenosis

3- Constrictive pericarditis

4- Myocardial infarction

5- Aortic regurgitation

[ Q: 1327 ] MRCPass - Cardiology

A 70 year old man with complete
heart block has had a VVI permanent
pacemaker implanted a week ago.

Answer & Comments

Answer: 3- Constrictive pericarditis

The patient has the clinical features of
constrictive pericarditis. In constrictive

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pericarditis, an early diastolic sound is heard
(pericardial knock). This sound is due to
turbulence caused by the arrest of rapid
ventricular filling into a non-distensible
pericardial sac.

[ Q: 1329 ] MRCPass - Cardiology

A 70 year old man has a nine month
history of worsening breathlessness. His blood
pressure is 120/90 mmHg, O 2 sats 89% on air,
temperature is 36.5°C, there is a systolic
murmur heard throughout the precordium.

Blood tests show

Hb 14 g/dl

WCC 5 x 1071-

Platelets 280 x 1071-

urea 7 pmol/l

creatinine 75 pmol/l

sodium 142 mmol/l

potassium 4.2 mmol/l

cholesterol 6.2 mmol/l

triglyceride 2.1 mmol/l

Which of the following is most likely?

1- Dilated cardiomyopathy

2- Aortic regurgitation

3- Aortic stenosis

4- Pericardial effusion

5- Coarctation of the aorta

Answer & Comments

Answer: 3- Aortic stenosis

There is evidence of left sided heart failure
clinically. The murmur throughout the
praecordium and narrow pulse pressure
suggest aortic stenosis. The patient is also
predisposed to this by a high cholesterol.

^ [ Q: 1330 ] MRCPass - Cardiology

A 50 year old man had a ventricular

fibrillation cardiac arrest whilst at a railway
station. He was successfully resuscitated by a
passerby. Coronary angiography showed no
stenotic lesions in the coronary arteries.

Which is the next management step?

1- Lifelong amiodarone

2- Implantable cardiac defibrillator

3- Procainamide

4- Permanent pacemaker

5- No further action necessary

Answer & Comments

Answer: 2- Implantable cardiac defibrillator

A cardiac electrophysiological study would be
necessary to help confirm w hether this
patient has inducible ventricular tachycardia,
and ablation of the pathways if so. However in
a young patient with no coronary artery
disease demonstrable to revascularise, ICD is
necessary to treat a possible further cardiac
arrest.

iinptaftiitbic

CaidioviHter

DHibiillator

Pacing LimiIs

tdl Atrium

Right

Lfclt Vfntride

^ [ Q: 1331 ] MRCPass - Cardiology

fl -

* A 25 year old biology student
presents with palpitations and has the ECG
(above) recorded. Adenosine is given at 6mg
and 12mg intravenously. He felt nauseous for
a few seconds and there is a rhythm change to
sinus rhythm.

How does adenosine work?

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1- Decrease sensitivity of conduction bundle
to electrolytes

2- Altering Purkinje fiber response

3- Blocking an accessory pathway

4- Blocking AV node conduction

5- QT prolongation

Answer & Comments

Answer: 4- Blocking AV node conduction

Adenosine w orks by slow ing atrioventricular
(AV) conduction, hence breaking the re-entry
circuit which can be a AVNRT or AVRT in supra
ventricular tachycardia.

and systolic BP is 120 mmHg in the left arm,
80 mmHg systolic in the right arm.

Which one of the following is o feature of
severity requiring immediate (surgical) action?

1- Persistent vomiting

2- Headache

3- Pulmonary oedema on the CXR

4- Hypertension

5- Loud diastolic murmur in the aortic area

Answer & Comments

Answer: 5- Loud diastolic murmur in the aortic
area

[ Q: 1332 ] MRCPass - Cardiology

A 10 year old patient has Down's
syndrome. He has over the past year become
progressively more breathless, is losing weight
and feeling lethargic. He is also becoming blue
when running with the dog during walks.

Which of the following cardiac lesions might
be responsible?

1- Atrial septal defect

2- Aortic regurgitation

3- Tetralogy of fallot's

4- Mitral stenosis

5- Ventricular septal defect

Answer & Comments

Answer: 5- Ventricular septal defect

An endocardial cushion defect (betw een the
atrial and ventricular septum) can lead to ASD
or VSD. With rapid deterioration a VSD is most
likely to cause breathlessness and cyanosis.

[ Q: 1333 ] MRCPass - Cardiology

A 60 year old man presents with
central crushing chest pain radiating to the
back. He has a w eak pulse in the right arm

In aortic dissection, hypertension should be
treated with an infusion such as labetalol. A
loud diastolic murmur in the aortic area
suggests aortic regurgitation. Aortic
regurgitation and pericardial effusion
(haemopericardium) suggest dissection down
to the aortic root. These features, or persisting
chest pain suggest that the patient requires
prompt surgery.

[ Q: 1334 ] MRCPass - Cardiology

A 66 year old man presents with
tearing chest pain radiating to the back. The
pain started 5 hours ago and is continuous. He
has a past medical history of previous stroke,
hypertension and osteoarthritis. His blood
pressure is 180/95 mmHg. There is an early
diastolic murmur in the aortic area and the
chest X ray showed a widened mediastinum.
An urgent CT of his chest with contrast shows
a dissection flap.

What is the best treatment at present?

1- Iv amlodipine

2- Iv labetalol

3- Iv tirofibran

4- Oral sodium nitroprusside

5- Clopidogrel

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Answer & Comments

Answer: 2- Iv labetalol

Answer & Comments

Answer: 2- Anticoagulation with warfarin

The history and CT scan findings confirm aortic
dissection in this case. Blood pressure control
is vital in the early management of aortic
dissection, prior to considering cardiac
surgery. The best initial treatments are iv
labetalol or iv sodium nitroprusside.

Aortic dissection - arrow points to the flap

[ Q: 1335 ] MRCPass - Cardiology

A 70 year old woman has a history of
palpitations for 4 months. An ECG at that time
showed atrial fibrillation. She was given
digoxin, diuretics and aspirin. She now
presents with two short-lived episodes of
altered sensation in the left face, left arm and
leg. She also had intermittent dysphasia.
There is poor coordination of the left hand.

An echocardiogram was normal as was a CT
head scan.

The patient has thrombotic events related to
atrial fibrillation, hence formal anticoagulation
is recommended.

The Age and stroke gives her a CHADS-65
score of 3. A CHADS-65 score of 2 or above
suggests the need for warfarinisation.

[ Q: 1336 ] MRCPass - Cardiology

A 13 year boy had a syncopal
episode followed by generalised jerking of all
his limbs, whilst having dental filling.

He was particularly nervous about the
procedure. When he was assessed in casualty,
his BP was 145/80, 0 2 sats were 99% and ECG
showed normal sinus rhythm.

Whot is the likely diagnosis?

1- Generalised tonic clonic seizures

2- Vasovagal syncope

3- Carotid sinus hypersensitivity

4- VF arrest

5- Meningitis

Answer & Comments

Answer: 2- Vasovagal syncope

Vasovagal syncope is not uncommon during a
procedure which a patient is frightened of.
There may be transient brain hypoxia which
may caused generalised seizure like activity.

Whot is the most appropriate next step in
management?

1- Carotid endarterectomy

2- Anticoagulation with warfarin

3- Clopidogrel

4- Corticosteroid treatment

5- No action

[ Q: 1337 ] MRCPass - Cardiology

A 60 year male diabetic presents to
the clinic. He takes metformin 850 mg tds,
bendrofluazide 2.5 mg and asprin 75 mg daily.
He has had a previous myocardial infarction
but is currentl asymptomatic. His body mass
index was 33.5 kg/m * 1 2 3 4 5 , he has a pulse of 90
beats per minute and a blood pressure of

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160/9 mmHg. His cholesterol concentration is
3.8 mmol/l (< 5.5).

Whot is the most appropriate therapy for this
patient?

1- Ramipril

2- Clopidogrel

3- Nicorandil

4- Orlistat

5- Simvastatin

ECG in WPW showing short PR interval and
rapid upstroke in WPW

Answer & Comments

Answer: 1- Ramipril

This patient has vascular disease and several
vascular risk factors. An ACE inhibitor would
reduce cardiovascular risk as suggested by the
HOPE study.

[ Q: 1338 ] MRCPass - Cardiology

A 21 year-old woman has a history of
palpitations and light headedness. ECG shows
short PR interval and inferior Q waves. Her
symptoms improve with atenolol 25 mg/day
but she has had two short episodes of similar
symptoms in the previous 24 hours.

What is the long-term management of choice?

[ Q: 1339 ] MRCPass - Cardiology

A 55 year old man presented with
chest pain, facial flushing and elevated jugular
venous pressure but no leg oedema. He had
been exposed to tuberculosis in childhood,
had a strongly positive tuberculin test and had
been followed up in the tuberculosis
surveillance program with regular chest x-rays,
but had never been diagnosed with
tuberculosis. Chest x-ray on presentation
showed calcified plaques and masses in the
pericardium and mediastinum.

Coronary angiography showed 70% stenosis in
the left anterior descending artery. Cardiac
catheterization showed equalisation of
diastolic pressures in all four chambers, with a
positive square root sign.

1- Anticoagulation

What is the likely diagnosis?

2- Oral amiodarone

1- Pericardial effusion

3- Oral digoxin

4- Increase the dose of atenolol

5- Radiofrequency ablation

Answer & Comments

Answer: 5- Radiofrequency ablation

The diagnosis is w olff Parkinson white
syndrome and the patient has atrial
tachycardias which are not controlled by
medical therapy. She should be referred to a
cardiac physiologist for radiofrequency
ablation of the accessory pathway.

2- Cardiac tamponade

3- Constrictive pericarditis

4- Sarcoidosis

5- Angina

Answer & Comments

Answer: 3- Constrictive pericarditis

The cardiac catheter data shows a pattern of
ventricular diastolic pressure characteristic of
constrictive pericarditis. Tuberculous
pericarditis is seen in l%-2% of all cases of
pulmonary tuberculosis and can lead to

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constriction. Treatment is with corticosteroids
and anti TB therapy.

The atrial waveform manifests:

-augmented "a" wave, reflecting enhanced
atrial contraction into a stiff ventricle

-a rapid "x" descent attributable to
subsequent accelerated atrial relaxation

systolic murmur heard at the base of the
heart.

The inheritance of this condition is most likely:

1- Mitochondrial inheritance

2- X-linked dominant

3- X-linked recessive

4- Autosomal recessive

-a steep "y" descent reflecting rapid,
resistance-free early diastolic filling.

Right and left heart chamber filling pressures
are typically increased and equalized (LVEDP =
RVEDP), reflecting the common constraining
effects of the pericardium.

Traces showing equalisation of diastolic
pressures in constrictive pericarditis

[ Q: 1340 ] MRCPass - Cardiology

An 30 year old man presents with a
history of syncope related to exercise. There is
a family history of sudden cardiac death. On
examination, the carotid pulse is jerky, there is
a double apical pulsation. On auscultation
there is a fourth heart sound, an ejection

5- Autosomal dominant

Answer & Comments

Answer: 5- Autosomal dominant

Hypertrophic obstructive cardiomyopathy is
most commonly of Autosomal dominant
inheritance. It occurs in at least on in 1,000 to
one in 500 of the general population.

[ Q: 1341 ] MRCPass - Cardiology

A 30 year old man is seen annually in
the cardiac clinic. During auscultation of his
heart there is wide fixed splitting of the
second heart sound.

In which of following conditions does this
occur?

1- Atrial septal defect

2- Aortic regurgitation

3- Constrictive pericarditis

4- Ebstein's anomaly

5- Right Bundle Branch Block

Answer & Comments

Answer: 1- Atrial septal defect

Wide fixed splitting is seen in ASD. In RBBB
there is wide splitting of S2 but it not fixed.

[ Q: 1342 ] MRCPass - Cardiology

A 65 year old lady has recently had a
cholecystectomy 2 days ago. She is now very
breathless, has central pleuritic chest pain and
feels dizzy. She is only able to say a few words

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and looks pale. Examination reveals a sinus
tachycardia and flow murmur across the aortic
area. Her blood pressure is is 85 / 50 mmHg,
0 2 saturations are 85% on 6 litres of 0 2 . ECG
shows non specific T wave abnormalities.

What should be the next management step?

1- CT pulmonary angiogram

2- Intravenous heparin

3- Coronary angiogram

4- Thrombolysis with tenecteplase

5- Transthoracic echocardiography

Answer & Comments

Answer: 4- Thrombolysis with tenecteplase

This patient has recently had surgery, and her
presentation would be consistent with life
threatening massive pulmonary embolus. She
is medically too unstable to wait for a
diagnostic test in radiology, thus thrombolysis
should be done immediately. If this does not
work then the patient may need ventilation,
CT to confirm the diagnosis and surgical
embolectomy.

[ Q: 1343 ] MRCPass - Cardiology

A 75 year old man is admitted with
sudden onset shortness of breath, poor
exercise tolerance and ankle oedema.

Which of the following laboratory test would
identify the reason for his presentation?

1- Alpha 1 antitrypsin levels

2- Serum electrophoresis

3- Serum triglycerides

4- Brain natriuretic peptide

5- Urea and electrolytes

Answer & Comments

Answer: 4- Brain natriuretic peptide

The clinical scenario fits with acute pulmonary
oedema. Brain or B type natriuretic peptide is

increasingly used as a marker of congestive
heart failure. It has high specificity for the
condition. It is released by ventricular
cardiomyocytes due to stretch as part of the
pathophysiology of cardiac failure.

[ Q: 1344 ] MRCPass - Cardiology

A 55 year old man complains of
dyspnoea on exertion. He recently returned
from Africa on a long holiday. He has distant
heart sounds on auscultation of the chest. A
chest radiograph reveals a thin rim of
calcification surrounding the cardiac outline.

Which of the following is likely?

1- Myocarditis

2- Silent myocardial infarction

3- Subacute bacterial endocarditis

4- Small pneumothorax

5- Constrictive pericarditis

Answer & Comments

Answer: 5- Constrictive pericarditis

The likely diagnosis is constrictive pericarditis.
The is probably related to previous
tuberculous infection because of the
calcification. Acute pericarditis is less likely to
cause calcification.

Rim of calcification seen on the CXR

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[ Q: 1345 ] MRCPass - Cardiology

A 45 year old lady has previous
history of rheumatic fever. She has a loud first
heart sound and a diastolic murmur
suggestive of mitral stenosis.

Which of these is the best indicator of severe
mitral stenosis?

1- Increased pulse pressure

2- Clubbing

3- Loud second heart sound and right
parasternal heave

4- Tapping apex beat

5- Rumbling mid diastolic murmur

Answer & Comments

Answer: 3- Loud second heart sound and right
parasternal heave

This patient isolated systolic hypertension
(systolic BP >160 mmHg). Based upon studies
such as the Systolic Hypertension in the
Elderly Program (SHEP) the BHS guidelines
suggest treatment with either Calcium
antagonists or Diuretics (C or D).

[ Q: 1347 ] MRCPass - Cardiology

A 65 year old man experiences
substernal chest pain upon exertion for 6
months. An electrocardiogram shows T wave
inversion in the anterolateral leads at rest. He
has a total serum cholesterol of 8 mmol/l. On
angiography, he has a 95% narrow ing of the
left anterior descending artery.

Which of following events is likely occur in this
patient?

1- Pulmonary embolism from a left ventricular
mural thrombus

A loud P2 and features of right heart strain is
suggestive of pulmonary hypertension, hence
severe mitral stenosis.

[ Q: 1346 ] MRCPass - Cardiology

A 80 year old woman is referred by
her GP for high blood pressure. Over the last
three months her pressure has been recorded
at around 175/80 mmHg for 3 occasions. She
has a body mass index of 26 kg/m * 1 2 3 4 5 and is a
nonsmoker.

Which of the following is the most appropriate
treatment for her blood pressure?

1- Calcium channel blocker

2- Beta blocker

3- Alpha Blocker

4- Angiotensin Receptor Blocker

5- Angiotensin Converting Enzyme (ACE)
Inhibitor

2- Pulmonary embolism from thrombosis in a
internal jugular vein

3- A systemic artery embolus from thrombosis
in a the hepatic vein

4- A systemic artery embolus from a left
ventricular mural thrombus

5- A systemic artery embolus from a left atrial
appendage thrombus

Answer & Comments

Answer: 4- A systemic artery embolus from a
left ventricular mural thrombus

A significant stenosis of the left anterior
descending artery may lead to infarction of
anterior region of the left ventricle. Thrombus
may form on an area of the dyskinetic
ventricle (mural thrombus). Therefore he at
risk of arterial embolus of thrombus from the
LV.

Answer & Comments

Answer: 1- Calcium channel blocker

[ Q: 1348 ] MRCPass - Cardiology

A 60 year old man presents with
sharp chest pain radiating to the epigastrium.

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He has ST elevation in the anterior leads on his
ECG and is thrombolysed. The chest pain
persists despite thrombolysis. He develops a
raised JVP up to the ear lobes and BP drops to
95/60. There are signs of pulsus paradoxus.

What is the likely diagnosis?

1- Aortic dissection

2- Pericarditis

3- Pulmonary embolism

4- Anterior Ml with myocardial rupture

5- Patent ductus arteriosus

Answer & Comments

Answer: 1- Aortic dissection

Aortic dissection can present with pain
radiating to the epigastric region or back. If
the dissection flap involves close to the aortic
root, then the coronary flow can be affected,
causing either inferior Ml in right coronary
artery or anterior Ml in left anterior
descending artery involvement. Cardiac
tamponade can also be caused by dissection
(blood flow ing into pericardial space) and
leading to a raised JVP and pulsus paradoxus.

In this patient the blood pressure is too high
to safely administer thrombolysis. GTN should
be given to lower the blood pressure in the
first instance and to vasodilate the coronary
arteries.

^ [ Q: 1350 ] MRCPass - Cardiology

# A 72 year old man is reviewed at
medical outpatient clinic complaining of
tiredness. He takes amiodarone, aspirin,
atenolol and atorvastatin. His heart rate on
examination is 85 bpm. Recent 24-hr ECG
shows sinus rhythm throughout with
occasional ventricular ectopics.

Investigations reveal:

Free T 4 32 nmol/I (9-22)

TSH <0.02 mU/l (0.4-4)

What is the best management strategy for this
patient?

1- Stop amiodarone only

2- Stop amiodarone and start carbimazole

3- Stop amiodarone and start prednisolone

4- Check antithyroid antibodies

5- Prednisolone only

[ Q: 1349 ] MRCPass - Cardiology

A 60 year old man was admitted with
severe chest pain. On examination his Blood
Pressure was 205/115mm Hg.

ECG showed >2mm ST elevation in Leads V2-4.
He was given morphine and aspirin.

What is the next appropriate management?

1- IvtPA

2- Iv streptokinase

3- Iv GTN

4- Clopidogrel

5- Tirofiban

Answer & Comments

Answer: 3- Iv GTN

Answer & Comments

Answer: 2- Stop amiodarone and start
carbimazole

This patient has probable amiodarone-
induced hyperthyroidism.

The amiodarone was used to maintain sinus
rhythm in this patient who was admitted with
ischaemic heart disease and atrial
fibrillation/flutter that spontaneously settled.
The amiodarone should be discontinued, and
carbimazole started. When the patient is
euthyroid, the dose of carbimazole may be
reduced (amiodarone can stay in the system
for several weeks).

[ Q: 1351 ] MRCPass - Cardiology

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A 60 year old man who was previously
asymptomatic suddenly develops severe
anterior chest pain radiating to the back.
Within minutes, he becomes unconscious. He
has a history of hypertension.

1- Ramipril

2- Frusemide

3- Digoxin

4- Diltiazem

On examination, he has a blood pressure of
120 / 60 mmHg in the right arm and 105 / 55
mmHg in the left arm. An early diastolic
murmur was audible in the lower left sternal
edge.

5- Spironolactone

Answer & Comments

Answer: 3- Digoxin

Which of the following is the most likely
diagnosis?

1- Malignant hypertension

2- Internal carotid artery dissection

3- Acute myocardial infarction

4- Aortic dissection

5- Pulmonary embolus

Answer & Comments

Answer: 4- Aortic dissection

Digoxin toxicity can occur especially with renal
impairment. It typically causes nausea &
vomiting. ST depression occurs along with
bradycardia on the ECG. The patient may also
get xanthopsia (yellow vision).

Digoxin Effect

The acute history of sharp pain radiating to
the back is suggestive of aortic dissection. In
addition, there is predisposing risk factor of
hypertension and he collapses (suggesting
that the dissection flap may have involved
large vessels leading tow ards vascular
insufficiency) and hence the neurological
symptoms.

When the flap dissects down to the aortic
root, aortic regurgitation may also be found
(early diastolic murmur).

[ Q: 1352 ] MRCPass - Cardiology

A 62 year old man has atrial
fibrillation and was found to be in pulmonary
oedema clinically. He improves clinically in 3
days, but then begins to feel nauseous. His
creatinine has risen from 120 to 210 pmol/l.
He has ST changes on his ECG and complains
of altered vision.

Which of these drugs is the most likely cause
of the effects?

[ Q: 1353 ] MRCPass - Cardiology

A 60 year old man has had a
myocardial infarction. His pulse rate is 45 and
he is feeling lightheaded. Blood pressure is
90/65.

In which one of the following conditions is
temporary pacing indicated when symptoms
are present?

1- First degree heart block

2- Wenkebach

3- 2:1 Mobitz type II heart block

4- Left bundle branch block

5- Bifascicular block

Answer & Comments

Answer: 3- 2:1 Mobitz type II heart block

The first form of second degree heart block,
Mobitz type I (Wenkebach) is due to
progressive prolongation of PR interval and
then missing a beat. Mobitz type II second

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degree heart block can occur with 2:1 (only 1
QRS is conducted for 2 p waves) or 3:1. In a
patient who is compromised with symptoms
and hypotension, temporary pacing is
indicated.

[ Q: 1354 ] MRCPass - Cardiology

A 60 year old woman has atrial
fibrillation controlled with digoxin and beta
blocker. She has a previous history of
hypothyroidism but her last thyroid function
tests were normal. She feels lightheaded and
is brought to hospital.

Her renal function is abnormal and she has a
pulse rate of 35.

What is the likely diagnosis?

1- Myxedema crisis

2- Addisonian crisis

3- Hypercalcaemia

4- Sick sinus syndrome

5- Digoxin toxicity

Answer & Comments

Answer: 5- Digoxin toxicity

Factors which predispose to digoxin toxicity
are renal impairment, hypokalaemia,
hypomagnesaemia and hypercalcaemia. It can
lead to bradyarrhythmias - first degree heart
block and Wenkebach (Mobitz type II second
degree heart block is rare), and complete
heart block. Other features of digoxin toxicity
are xanthopsia (yellow vision), nausea &
vomiting and dyspnoea. The reversed tick sign
on the ECG is not a feature of toxicity but is
associated with digoxin use.

currently taking Ramipril 10 mg od and
Frusemide 80 mg OD.

What is the best treatment option?

1- Losartan

2- Amiodarone

3- Bisoprolol

4- Digoxin

5- Spironolactone

Answer & Comments

Answer: 3- Bisoprolol

Beta blockers improve mortality quality of life
in chronic heart failure (COPERNICUS,
MERITHF, CIBIS trials). They should be
initiated once patients are stable (rather than
in the acute setting) and can be used in all
classes of heart failure.

[ Q: 1356 ] MRCPass - Cardiology

A 50 year old lady has palpitations.
Her ECG shows a broad complex tachycardia.

Which of these features suggests that the
tachycardia is more likely to be of ventricular
origin ?

1- QRS of 180 ms

2- Left bundle branch block and left axis
deviation

3- P wave for every QRS complex

4- History of atrial fibrillation

5- Heart rate of 150

Answer & Comments

Answer: 1- QRS of 180 ms

[ Q: 1355 ] MRCPass - Cardiology

A 75 year old man with dilated
cardiomyopathy remains symptomatic in
NYHA class 2 group. He has chronic heart
failure. On examination his BP 150/95. He is

Features that favour VT :

QRS of > 140ms

dissociated p waves

history of ischaemic heart disease

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right bundle branch block with left axis
deviation

HR > 170 beats per minute

[ Q: 1357 ] MRCPass - Cardiology

A 50 year old woman has new
symptoms of palpitations. She has no previous
cardiac history. An ECG reveals atrial
fibrillation.

Which one of the following drugs is most likely
to restore sinus rhythm?

1- Diltiazem

Answer & Comments

Answer: 4- Posterior Ml

The changes of posterior myocardial infarction
are seen indirectly in the anterior precordial
leads. Leads VI to V3 face the endocardial
surface of the posterior wall of the left
ventricle. As these leads record from the
opposite side of the heart instead of directly
over the infarct, the changes of posterior
infarction are reversed in these leads. The R
waves increase in size, becoming broader and
dominant, and are associated with ST
depression and upright T waves.

2- Digoxin

3- Atenolol

4- Flecainide

5- Labetalol

Answer & Comments

Answer: 4- Flecainide

Flecainide is a class Ic antiarrhythmic drug. It
helps restoration of sinus rhythm and prevent
recurrence of AF. Flecainide may prolong QT
interval. The drug was used in the Cardiac
Arrhythmia Suppression Trial (CAST) trial, and
was associated with increased mortality in
patients with ischaemic heart disease.

[ Q: 1359 ] MRCPass - Cardiology

A 29 year old lady complained of
transient blurred vision following a long flight.
She has no other past medical history and is
on no regular medications. On examination,
there were no audible heart murmurs. CT scan
of her head revealed no abnormality.

What is the most likely underlying cause of her
presentation?

1- Antithrombin III deficiency

2- Atrial septal defect

3- Brain tumour

4- Patent foramen ovale

5- Vestibulitis

[ Q: 1358 ] MRCPass - Cardiology

L-l

A 53 year old man presents with

Answer & Comments

severe

crushing chest pains. His ECG showed

Answer: 4- Patent foramen ovale

dominant R waves in VI and V2 leads. The T
waves were also tall.

What is the most likely cause?

1- Lateral Ml

The clinical scenario is one in which a
thrombus has developed probably in the leg,
and embolised via a patent foramen ovale,
causing a transient ischaemic attack.

2- Anterior Ml

3- Inferior Ml

4- Posterior Ml

5- Pulmonary embolism

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Patent Foramen Ovale

[ Q: 1360 ] MRCPass - Cardiology

A 60 year old man is acutely short of
breath. ECG shows atrial fibrillation. His HR is
170 and BP is 110/70. There are no cardiac
murmurs but he has a raised JVP and few
basal crackles in the lungs.

Which of these is the best monogement
strategy?

1- Atenolol, frusemide, low molecular weight
heparin

2- Digoxin and low molecular weight heparin

3- Iv amiodarone, iv frusemide

4- Digoxin, frusemide, low molecular weight
heparin

5- Frusemide and DC cardioversion

Answer & Comments

Answer: 4- Digoxin, frusemide, low molecular
weight heparin

The patient has evidence of pulmonary
oedema related to tachycardia and AF. She
needs anticoagulation, rate control and
diuresis to relieve pulmonary oedema. In
addition, if her blood pressure allows, a
nitrate (GTN) infusion would be helpful. DC
cardioversion should be considered if rate
control is poor but is associated with high risk
of thromboembolism if the AF is not new.

[ Q: 1361 ] MRCPass - Cardiology

A 23 year old lady has a 6 month
history of fever and pains in her elbows, wrist
and knee joints. There is a soft systolic
murmur and a pericardial rub on auscultation.

Her bloods reveal:

Hb 12.0 g/dl, WCC 10 x 10 9 /L, platelets 280 x
10 9 /L, urea 5 pmol/l, creatinine 70 pmol/l,
sodium 138 mmol/I, potassium 3.8 mmol/I,
bilirubin 18 pmol/l, AST 18 U/l, ALP 180 U/l,
albumin 35 g/l, ESR 100 mm/hr, CRP 140 mg/I.

Which of the following is the likely diagnosis?

1- Viral pericarditis

2- Rheumatic fever

3- Subacute bacterial endocarditis

4- Atrial myxoma

5- Polyarteritis nodosa

Answer & Comments

Answer: 2- Rheumatic fever

This patient has polyarthritis, carditis (2 major
criteria), fever and raised inflammatory
markers (2 minor criteria). The history is
consistent with rheumatic fever ((3 haemolytic
strep Group A) infection.

Rh eu m atic Fever/

Rheumatic Heart Disease

Major criteria : Carditis,
polyarthritis, chorea,
subcutaneous nodules,
and erythema marginatum

[ Q: 1362 ] MRCPass - Cardiology

A 55 year old Afro-Caribbean man in
the outpatient clinic has uncomplicated
essential hypertension. His blood pressure

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today is 160/100 mmHg despite optimization
of non-pharmacological therapy.

Which one of the following drugs should be
used?

1- Atenolol 50mg od

2- Amlodipine 5mg od

3- Enalapril 5mg bd

4- Nifedipine lOmg tds

5- Lisinopril 2.5mg od

Answer & Comments

Answer: 2- Amlodipine 5mg od

Studies indicate that drugs such as ACE
(angiotensin-converting enzyme) inhibitors
and Beta-receptor antagonists are less
effective in Afro-Caribbeans. The reason
appears to be related to the finding that the
renin-angiotensin-aldosterone (RAA) system is
commonly suppressed in the majority of Afro-
Caribbeans. As such, drugs that suppress the
RAA system are less likely to be effective.

Calcium-channel blockers (CCBs) and diuretics
appear to be more effective in this subgroup.
Short-acting CCBs do not provide prolonged
BP control, can cause reflex tachycardia and
may be associated with higher mortality.

Therefore, long-acting CCB should be the first-
line drug of choice. Ideally, a once-daily agent
with that provides a smooth 24-hour BP
control (e.g. Nifedipine LA 30mg od or
Amlodipine 5 mg od).

3- LDH

4- CK-MB

5- CK

Answer & Comments

Answer: 4- CK-MB

Troponins tend to be elevated for up to 14
days. CK-MB comes down to normal level
within 48-72 hours, and is the most specific of
the CK enzymes. Within 4 days of the first Ml,
the CK-MB fraction should not be raised, and
if so, indicates a possible second Ml.

^ [ Q: 1364 ] MRCPass - Cardiology

f -

A 65 year old patient has had a
previous myocardial infarction 5 years ago
followed by coronary artery bypass grafting.
She is on aspirin, ramipril and furosemide.
During review , she is well. Blood pressure is
140/70 mmHg, pulse is 80 and regular, JVP is
not raised. Her breath sounds are clear.

Which drug should be considered ?

1- Digoxin

2- Lisinopril

3- Carvedilol

4- Clopidogrel

5- Tirofibran

Answer & Comments

Answer: 3- Carvedilol

[ Q: 1363 ] MRCPass - Cardiology

A 65 year old patient diagnosed as
having myocardial infarction on admission to
hospital. 4 days later he suffered an attack of
prolonged chest pain while still in the hospital.

Which of the enzymes would best help in
diagnosing a possible second Ml?

1- Troponin I

2- Troponin T

The Carvedilol Prospective Randomized
Cumulative Survival Study in patient with
severe chronic heart failure was stopped early
because of a significant beneficial effect of
carvedilol on survival.

[ Q: 1365 ] MRCPass - Cardiology
A 70 year old man presents with an

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episode of collapse. He has had 3 similar
episodes recently. 2 years ago he suffered an
anterior myocardial infarction.

On examination he was orientated and
symptom-free with a regular pulse rate of 100
bpm, BP 140/80 mmHg and the apex beat was
displaced to the left. There was an apical
systolic murmur. There were no focal
neurological signs.

ECG showed sinus rhythm, Q waves and ST
segment elevation anteriorly without
reciprocal depression. CXR suggests left
ventricular aneurysm.

Whot is the likely couse of the col lapses?

1- Acute anterior myocardial infarction

2- Cerebrovascular accident

3- Epileptic seizure

4- Left ventricular aneurysm

5- Ventricular tachycardia

have spontaneously reverted to sinus rhythm.
An echocardiogram is normal.

Whot is the appropriate management?

1- Advice to stop drinking

2- Amiodarone

3- Sotalol

4- Aspirin 3 months

5- Warfarin for one month

Answer & Comments

Answer: 1- Advice to stop drinking

Excessive Alcohol is a well recognized cause of
atrial fibirillation, likely to be the cause in this
case. Ischaemic heart disease is unlikely, as is
structural heart disease in view of a normal
echocardiogram. Therefore, advice to stop
drinking is most likely to help maintain sinus
rhythm.

Answer & Comments

Answer: 5- Ventricular tachycardia

A patient with anterior Ml, likely ventricular
scarring with a collapse is likely to have
ventricular arrhythmias. The fact that there
are no focal neurological signs makes
thromboembolism or stroke unlikely.

Ventricular Tachycardia

[ Q: 1367 ] MRCPass - Cardiology

A 60 year old security guard presents
with sudden onset of severe crushing central
chest pain. The E.C.G shows sinus bradycardia
with ST segment elevation in leads II, III, aVF.

Where is the likely lesion?

1- Diagonal artery

2- Left anterior descending

3- Right coronary artery

4- Circumflex artery

5- Obtuse marginal artery

Answer & Comments

Answer: 3- Right coronary artery

[ Q: 1366 ] MRCPass - Cardiology

A 25 year old man is brought into
hospital with symptoms of alcohol
intoxication. An initial ECG reveals atrial
fibirillation. The next morning he was found to

The patient has an inferior myocardial
infarction. This area of the myocardium is
supplied by the right coronary artery. The sino
atrial node is also supplied by an artery which
arises from the right coronary artery and
hence there may be bradycardia or heart
block.

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[ Q: 1368 ] MRCPass - Cardiology

f | -

# A 65 year old man has presented
with chest pain and has anterior ST elevation
on the ECG which is thrombolysed with
tenecteplase. He becomes very breathless. On
examination, he has a loud pansystolic
murmur in the lower left sternal edge and
bilateral coarse crepitations in the lung bases.

Which of the following investigations is most
important to confirm the diagnosis?

1- Chest X ray

2- Transthoracic echocardiogram

3- CT pulmonary angiogram

4- Repeat ECG

5- Arterial blood gas

Answer & Comments

Answer: 2- Transthoracic echocardiogram

2- Regular outpatient follow up with
echocardiography

3- Anticoagulation with warfarin

4- Transoesphageal echocardiography

5- Refer for cardiac surgery

Answer & Comments

Answer: 2- Regular outpatient follow up with
echocardiography

The normal left ventricular function and
dimensions, as well as moderate mitral
regurgitation suggests that cardiac surgery can
be held off. She is in sinus rhythm and does
not require anticoagulation (left atrium is only
mildly enlarged - < 4cm is normal). Antibiotic
prophylaxis is necessary. Transoesophageal
echocardiography is not necessary unless she
is being considered for surgery, or there is
suspicion of endocarditis.

Although he is likely to have pulmonary
oedema, a CXR will not confirm the diagnosis.
With a large antero-septal Ml, he could have
either have mitral regurgitation (function or
papillary muscle damage) or a VSD causing the
systolic murmur. As this is in the lower left
sternal edge, it would be important to get an
urgent echocardiogram to confirm and refer
for cardiothoracic surgery.

[ Q: 1369 ] MRCPass - Cardiology

A 55 year old woman has a systolic
murmur which is discovered by the GP who
referred the patient for a cardiac opinion. She
has a transthoracic echocardiogram which
shows normal left ventricular function. There
is no significant cardiac enlargement and she
has a mitral valve prolapse with moderate
mitral regurgitation. The left atrium diameter
is 4.3 cm.

What is the most appropriate course of
action ?

1- No endocarditis prophylaxis necessary

[ Q: 1370 ] MRCPass - Cardiology

A 40 year old patient has a
transthoracic echocardiogram as a follow up.
He has a diagnosis of hypertrophic obstructive
cardiomyopathy. Clinically he has a systolic
murmur heard loudest in the right upper
sternal edge. His ECG shows grossly large QRS
complexes with LVH strain pattern.

Which of the following suggests highest risk
for sudden death?

1- A left ventricular outflow tract gradient of
20 mmHg

2- Tricuspid regurgitation

3- Systolic anterior motion of mitral valve

4- ECG showing ventricular ectopics

5- Interventricular septal thickness of 4 cm

Answer & Comments

Answer: 5- Interventricular septal thickness of
4 cm

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The LV outflow tract gradient is not
significantly high in this patient, however, this
may be variable with exercise. The large
interventricular septal thickness of 4 cm
(normal <1.3 cm) suggests very hypertrophic
myocardium and high risk of outflow tract
obstruction with exertion.

[ Q: 1371 ] MRCPass - Cardiology

A 60 year old man presents with
breathlessness, visual blurring and headaches
to A&E. During examination, he has a
generalised tonic clonic seizure. He has a
blood pressure of 240/120. Fundoscopy
reveals retinal haemorrhages and exudates.
The optic disc margin is not visualised.

Which of the following medications is first
line?

1- Sodium nitroprusside

2- Labetalol

mitral stenosis has atrial fibrillation. She
presents unwell with fast AF and was DC
cardioverted successfully.

Which of the following medications is most
effective for maintenance of sinus rhythm?

1- Digoxin

2- Amiodarone

3- Atenolol

4- Diltiazem

5- Labetalol

Answer & Comments

Answer: 2- Amiodarone

Amiodarone is most effective for maintenance
of sinus rhythm. However, because of its side
effect profile, in a young patient, it is usually
worth trying a beta blocker or calcium blocker
before treating with amiodarone.

3- Diltiazem

4- Atenolol

5- Bendrofluazide

Answer & Comments

Answer: 1- Sodium nitroprusside

Malignant hypertension can present with
pulmonary oedema, chest pain, headache,
visual disturbance and also seizures. A
fundoscopic examination may reveal flame¬
shaped retinal hemorrhages, soft exudates, or
papilledema.

[ Q: 1373 ] MRCPass - Cardiology

# A 25 year old man is being
investigated for hypertension. The pressure
data from cardiac catheterisation are as follow
s: RA 2 mm Hg, RV 22/2 mm Hg, PA 25/14 mm
Hg, LA 7 mm Hg, LV 210/0-8 mm Hg, Aorta
180/100 mm Hg, Femoral artery 95/60 mm
Hg.

What is the likely diagnosis?

1- Ascending aortic aneurysm

2- Aortic stenosis

3- Coarctation of the aorta

Sodium Nitroprusside has an immediate onset
of action and short half-life. It acts by causing
relaxation of vascular smooth muscle,
resulting in vasodilation and inotropy. The
dose is 0.25-10 mcg/kg/min IV. IV hydralazine,
beta blockers and calcium channel blockers
can also be used.

[ Q: 1372 ] MRCPass - Cardiology
A 35 year old patient with mild

4- Aortic dissection

5- Aortic regurgitation

Answer & Comments

Answer: 3- Coarctation of the aorta

The history of hypertension and the pressure
data suggest a diagnosis of coarctation of the
aorta.

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Coarctation of the aorta

[ Q: 1374 ] MRCPass - Cardiology

A 60 year old lady is known to have
severe mitral stenosis. She presents with
breathlessness.

On examination , which one of the following
features is expected?

1- Clubbing

2- Loud first heart sound

3- Wide pulse pressure

4- Ejection systolic murmur

5- Small left atrium

Answer & Comments

Answer: 2- Loud first heart sound

A loud first heart sound and tapping apex beat
are common in significant mitral stenosis. A
narrow pulse pressure is expected in severe
mitral stenosis. Left atrium is inevitably dilated
on CXR and echocardiography.

[ Q: 1375 ] MRCPass - Cardiology

A 45 year old patient has been
commenced on nifedipine for hypertension.

Which of the following effect describes the
action of nifedipine?

1- Reduced sympathetic activity

2- Decreased activation of renin angiotensin
aldosterone axis

3- Reduced peripheral capillary pressure

4- Reduced peripheral vascular resistance

5- Decrease vascular release of nitric oxide

Answer & Comments

Answer: 4- Reduced peripheral vascular
resistance

Nifedipine is a dihydropyridine. The
mechanism of action is smooth muscle
relaxation and reduction in peripheral vascular
resistance. However, peripheral capillary
pressure is increased (this causes oedema in
the ankles), there is increased sympathetic
activity and increased activation of the renin
angiotensin aldosterone axis. There is also
increased vascular release of nitric oxide.

[ Q: 1376 ] MRCPass - Cardiology

A 70 year man has been short of
breath for 1 year. An electrocardiogram shows
T wave inversion and q waves in the
anterolateral leads at rest. He has
cardiomegaly on the chest X ray. Clinical
examination shows a third heart sound, a soft
systolic murmur in the mitral area and also
bilateral inspiratory crepitations in his lungs.

Which of the following is he at risk of?

1- Deep vein thrombosis

2- Pulmonary embolus

3- Systemic arterial embolus from mural
thrombus

4- Venous thrombosis due to mural thrombus

5- Coronary artery thrombus due to mural
thrombus

Answer & Comments

Answer: 3- Systemic arterial embolus from
mural thrombus

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This man has features indicating that he has
an enlarged left ventricle from previous
anterior myocardial infarction in the LAD
artery territory. Poor LV function also causes
his symptoms of heart failure. He is at risk of
developing mural thrombus with embolus to
the arterial circulation.

[ Q: 1377 ] MRCPass - Cardiology

A 45 year old man was referred by
the GP for evaluation of a murmur. On
examination, he was found to have a slow
rising pulse and ejection systolic murmur in
the aortic area. Aortic stenosis was suspected.

In a patient presenting with aortic stenosis,
which of following features would be helpful in
establishing a diagnosis of congenital bicuspid
valve?

1- Calcified leaflets

2- Old age

3- A systolic ejection click

4- Commissural fusion on the echocardiogram

5- History of rheumatic fever

Answer & Comments

Answer: 3- A systolic ejection click

4- Pericarditis

5- Myocardial infarction

Answer & Comments

Answer: 3- Constrictive pericarditis

Constrictive pericarditis leads to signs of right
sided heart failure which are listed above.
There is also a prominent and rapid X and Y
descent of the waveform.

[ Q: 1379 ] MRCPass - Cardiology

A 57 year old lady who had a past
history of Myocardial Infarction and
subsequent CABG was known to have left
ventricular dysfunction on the
echocardiogram. She has no symptoms at
present. She was on aspirin, ramipril and
diuretic. On examination there were no signs
of heart failure.

What drug should be added next?

1- Amlodipine

2- Bisoprolol

3- Clopidogrel

4- Atorvastatin

5- Digoxin

An aortic ejection sound (ejection click) soon
after SI is especially common if a bicuspid
aortic valve is present.

Answer & Comments

Answer: 2- Bisoprolol

[ Q: 1378 ] MRCPass - Cardiology

A 40 year old lady has presented
with breathlessness. Her JVP is noted to be
raised. Manometry reveals a rapid Y descent.

On examination, she has hepatomegaly,
ascites and ankle oedema.

What is the diagnosis?

1- Dilated cardiomyopathy

2- Left ventricular failure

3- Constrictive pericarditis

In a patient with left ventricular dysfunction
and known history of ischaemic heart disease,
a beta blocker should be added (CIBIS II
Study).

[ Q: 1380 ] MRCPass - Cardiology

A 35 year old lady has progressive
shortness of breath. Following an
echocardiogram, she is found to have likely
rheumatic mitral stenosis is now being
considered for percutaneous mitral
valvuloplasty.

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Which of the following would contraindicate
this procedure?

1- Dilated left atrium

2- Atrial fibrillation

3- Aortic regurgitation

4- Heavy calcification of the mitral valve

5- Long history of mitral stenosis

Answer & Comments

Answer: 4- Heavy calcification of the mitral
valve

The contraindications tow ards valvuloplasty
are heavy MV calcification, thrombus in the
left atrial appendage on transoesophageal
echocardiography and severe mitral
regurgitation. These patients are indicated for
mitral valve surgery instead.

[ Q: 1381 ] MRCPass - Cardiology

A 25 year old man whose brother
had hypertrophic cardiomyopathy was
referred for a cardiological assessment. His
echocardiogram confirmed the condition.

Which one of following echocardiographic
features is the most important risk factor for
sudden cardiac death?

1- Thickness of septal wall

2- Systolic anterior motion of the mitral valve

3- Severity of mitral regurgitation

4- Gradient across left ventricular outflow
tract

5- An enlarged left atrium

Answer & Comments

Answer: 1- Thickness of septal wall

[ Q: 1382 ] MRCPass - Cardiology

A 55 year old patient had myocardial
infarction 6 days ago. He suddenly develops
dyspnoea, cough and frothy sputum. For the
first time a harsh systolic murmur is heard
over the praecordium.

This sequence of events might be caused by:

1- Pulmonary embolism

2- Aortic dissection

3- Tricuspid regurgitation

4- Ruptured papillary muscle

5- Ruptured aortic cusp

Answer & Comments

Answer: 4- Ruptured papillary muscle

Following an Ml, ruptured papillary muscle or
interventricular septum is most likely to cause
the combination of pulmonary oedema and
new murmur (either mitral regurgitation or
due to VSD).

[ Q: 1383 ] MRCPass - Cardiology

A 30 year old man is brought to A &
E with severe acute chest pain radiating to the
back. He is pale and anxious.

On examination the blood pressure is 150/90
mmHg and he was noted to have blue sclerae.

Which of the following conditions has
predisposed to this complication?

1- Coarctation of the aorta

2- Ischaemic heart disease

3- Rheumatic fever

4- Hypertrophic cardiomyopathy

5- Marfan's syndrome

The greater thickness of septum, the more
likelihood of left ventricular outflow tract
obstruction. The next most important factor
would be the gradient across the outflow
tract.

Answer & Comments

Answer: 5- Marfan's syndrome

Marfan's syndrome is one of the causes of
blue sclerae. The clinical diagnosis is aortic

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dissection. Other predisposing disorders to
aortic dissection are: essential hypertension,
atherosclerosis , bicuspid aortic valve,
connective tissue disorders, Marfan's
syndrome, Ehlers-Danlos syndrome, adult
polycystic kidney disease.

[ Q: 1384 ] MRCPass - Cardiology

A 68 year old man with severe aortic
stenosis presented with melaena. Upper Gl
endoscopy was normal.

Whot is the likely couse of Gl bleeding?

1- Haemorrhoids

2- Caecal carcinoma

3- Duodenal ulcer

4- Angiodysplasia

5- Ulcerative colitis

Answer & Comments

Answer: 4- Angiodysplasia

Angiodysplasia is the most common vascular
abnormality of the Gl tract. After
diverticulosis, it is the second leading cause of
lower Gl bleeding in patients older than 60
years. Angiodysplasia has been reported to be
associated with aortic stenosis.

Angiodysplasia

[ Q: 1385 ] MRCPass - Cardiology
A 35 year old man has a dominant R

in lead VI on the ECG during routine
examination.

Which one of the following is o recognised
couse?

1- Pericarditis

2- Turner's syndrome

3- Dextrocardia

4- Aortic stenosis

5- Tricuspid regurgitation

Answer & Comments

Answer: 3- Dextrocardia

A dominant R in lead VI on the ECG is
associated with :

-primary pulmonary HT

-Right bundle branch block (RBBB) (including
Ebstein's anomaly)

-Wolf-Parkinson-White syndrome Type A

-Dextrocardia

-Posterior Ml

-Duchene muscular dystrophy

Dextrocardia ECG

[ Q: 1386 ] MRCPass - Cardiology

A 62 year old lady with known
congestive heart failure and renal impairment.
She presents with features of worsening heart
failure, and also mentioned about recent
decreased urine output.

Whot is the most useful investigation for the
current condition?

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1- Electrolytes

2- Urea

3- Creatinine

4- Echocardiogram

5- Chest x ray

Answer & Comments

Answer: 4- Echocardiogram

A patient with symptoms of congestive cardiac
failure and renal impairment may have
deteriorating left ventricular function. This
may subsequently lead to cardiogenic shock,
the severity of LV function should be
documented to guide further management.

echocardiogram and refers the patient to you
with a report.

Which one of the following measures is
essential for the calculation of ejection
fraction ?

1- Ventricular wall thickness

2- Aortic valve diameter

3- Left ventricular end diastolic diameter

4- Stroke volume

5- Aortic valve velocity

Answer & Comments

Answer: 3- Left ventricular end diastolic
diameter

[ Q: 1387 ] MRCPass - Cardiology

A 28 year woman who is 20 weeks
pregnant is seen in the outpatient clinic and
noted to have a sustained blood pressure of
180/95 mmHg.

What is the most appropriate antihypertensive
therapy for this patient?

1- Methyldopa

2- Hydralazine

3- Nifedipine

4- Lisinopril

5- Atenolol

Answer & Comments

Answer: 1- Methyldopa

Methyldopa is the safest agent to use in the
first and second trimester of pregnancy.

Beta blockers may cause intrauterine growth
retardation. ACE inhibitors have also been
suggested to have teratogenic effects.

Ejection fraction measurement requires
measurements during both the end systolic
phase or end diastolic phases on the
transthoracic echocardiogram. This could be in
the form of ventricular diameter
measurement or area of the ventricle (in both
cases volumes are estimated by the echo
machine). The end systolic and end diastolic
volumes are then subtracted to obtain an
ejection fraction. Stroke volume itself is not
sufficient to give the ejection 'fraction' hence
needs comparison either systolic or diastolic
measurements.

[ Q: 1389 ] MRCPass - Cardiology

A 55 year old man with angina has
familial hypercholesterolaemia. His father and
uncle both have coronary heart disease.

Which one of the following is a typical feature
for the condition?

1- Plantar xanthomas

2- Autosomal recessive

3- Increased LDL concentrations

[ Q: 1388 ] MRCPass - Cardiology
A cardiac technician has done an

4- Hypertriglyceridaemia

5- Increased expression of LDL receptors

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Answer & Comments

Answer: 3- Increased LDL concentrations

Familial hypercholesterolaemia is an
autosomal dominant condition. There are
increased LDL concentrations due to reduced
numbers of LDL receptors.

Hypertriglyceridaemia does not usually occur
and HDL concentrations are usually
decreased. Tendon xanthomas occur, not
plantar xanthomas.

^ [ Q: 1390 ] MRCPass - Cardiology

A -

# A 48 year old male is referred with
impotence. He has a history of angina,
hypertension and type 2 diabetes.

Which one of the following drugs that he takes
would present a contraindication towards him
receiving Sildenafil?

1- Aspirin

2- Bendrofluazide

3- Isosorbide Mononitrate

4- Lisinopril

5- Metformin

Answer & Comments

Answer: 3- Isosorbide Mononitrate

There is a significant risk of hypotension when
sildenafil is used with nitrates. Hence it is
contraindicated in patients with a history of
angina or ischaemic heart disease.

2- Hypothyroidism

3- Ramipril use

4- Hyperkalaemia

5- Hypokalaemia

Answer & Comments

Answer: 5- Hypokalaemia

Hypomagnesaemia, hypokalaemia, and
hypercalcaemia are common metabolic
disturbances which may w orsen digoxin
toxicity.

Bradycardia, prolonged PR interval, shortened
QT interval and various forms of heart block
can occur in digoxin toxicity.

[ Q: 1392 ] MRCPass - Cardiology

A 70 year old man has a history of
syncope. He is found to have runs of
nonsustained ventricular tachycardia on ECGs
done in casualty. He has a past medical history
of hypertension. Investigations show a serum
magnesium of 0.6 mmol/l (0.75-1).

Which one of the following is the most likely
cause of hypomagnesaemia?

1- Calcium channel blockers

2- Diuretic therapy

3- Hyperphosphataemia

4- Diarrhoea and vomiting

5- Hypercalcaemia

[ Q: 1391 ] MRCPass - Cardiology

A 65 year old woman who is on
digoxin has symptoms of nausea and
dizziness. On examination, her heart rate is 35
bpm and an ECG shows prolonged PR interval
with first degree heart block.

Digoxin toxicity is more likely with which of the
following conditions?

Answer & Comments

Answer: 2- Diuretic therapy

Magnesium is present in greatest
concentration within the cell and is the second
most abundant intracellular cation after
potassium. Most renal reabsorption of
magnesium occurs in the proximal tubule and
the thick ascending limb of the loop of Henle.

1- Hypocalcaemia

Significant losses of magnesium that result in
hypomagnesemia may result from chronic

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diarrhea, laxative abuse, inflammatory bow el
disease, or neoplasm, diuretics (thiazide, loop
diuretics).

[ Q: 1393 ] MRCPass - Cardiology

A 30 year old lady was diagnosed
with long QT syndrome on routine
investigation for her insurance scheme.

Which one of the following drugs should be
started?

Answer & Comments

Answer: 3- Atrial septal defect

The second heart sound typically occurs with
A2 (aortic) and P2 (pulmonary).

Wide splitting can occur with delayed
pulmonary closure (P2) as in right bundle
branch block (RBBB), pulmonary stenosis and
ventricular septal defect (VSD). However,
FIXED wide splitting only occurs in ASD.

1- Atenolol

2- Digoxin

3- Amiodarone

4- Verapamil

5- Lignocaine

Answer & Comments

Answer: 1- Atenolol

In the management of a case of congenital
LQT syndrome, beta-blockade is usually
effective in preventing ventricular
tachyarrhythmias in the patient. If
symptomatic or if there are ventricular
arrhythmias documented, an intracardiac
cardioverter defibrillator should be
considered.

^ [ Q: 1395 ] MRCPass - Cardiology

fj -

# A 65 year old man with a history of
previous myocardial infarction presents with
palpitations. The ECG shows a broad complex
tachycardia at a rate of 150 beats/min and a
blood pressure of 90/55 mmHg.

The first line treatment should be:

1- Sotalol

2- Flecainide

3- Verapamil

4- Amiodarone

5- Lignocaine

Answer & Comments

Answer: 4- Amiodarone

[ Q: 1394 ] MRCPass - Cardiology

A 23-year-old male presented with a

2-year history of breathlessness on exertion.

On examination, there was a systolic murmur
in the pulmonary area and wide fixed splitting
of the second heart sound.

The likely diagnosis is ventricular tachycardia.
There are early signs of haemodynamic
instability (blood pressure is low). In this case,
amiodarone is the best agent as first line.
Lignocaine and flecainide can also be used but
are not considered first line when patients are
unstable.

In which of these conditions is fixed and wide
splitting of the second heart sound seen?

1- Fallot's tetralogy

2- Ventricular septal defect

3- Atrial septal defect

4- Pulmonary stenosis

5- Aortic regurgitation

[ Q: 1396 ] MRCPass - Cardiology

A 50 year old taxi driver is followed
up 8 weeks after an anterior myocardial
infarction. He underwent rescue angioplasty
with stenting to the LAD vessel following
failed thrombolysis. Since then he has had no
further symptoms of angina.

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Which should be the next investigation?

1- Bruce protocol exercise test

2- Modified Bruce protocol exercise test

3- Repeat coronary angiography to check stent
patency

4- Dobutamine stress echocardiography

5- Cardiac thallium scan

Answer & Comments

Answer: 1- Bruce protocol exercise test

For public vehicle drivers and heavy goods
vehicles drivers which are classed under
Group 2 entitlement by the DVLA, driving is
disqualified for 6 weeks for Ml, CABG and
angioplasty.

Following this, they have to undergo a Bruce
protocol exercise test to stage III without
significant ST changes or anginal symptoms.

[ Q: 1397 ] MRCPass - Cardiology

A 45 year old man has worsening
breathlessness. On examination, he has a
systolic blood pressure of 115 mmHg which
drops to 90mmHg during inspiration.

Which of the following conditions is most likely
to be present?

1- Congestive cardiac failure

2- Cardiac tamponade

3- Atrial fibrillation

4- Ventricular tachycardia

5- ICD implantation

Answer & Comments

Answer: 2- Cardiac tamponade

The clinical feature is pulsus paradoxus. This is
defined as a drop in blood pressure by more
than 20mmHg during inspiration. It is a
definite sign of cardiac tamponade, but may
occasionally occur with acute constrictive
pericarditis and COPD.

[ Q: 1398 ] MRCPass - Cardiology

A 50 year old lady is currently
asymptomatic but undergoes a
medical examination. Her ECG shows left
bundle branch block.

During clinical examination, which one of
these signs is likely to be found?

1- Tricuspid regurgitation

2- Systolic murmur in the mitral area

3- Third heart sound

4- Reversed splitting of the second heart
sound

5- Diastolic murmur in the pulmonary area

Answer & Comments

Answer: 4- Reversed splitting of the second
heart sound

The second heart sound comprises of aortic
(A2) and pulmonary (P2) component. In LBBB,
the aortic closure is delayed because the left
ventricle contracts later. This then causes
reversed splitting (A2P2 ? P2A2) of the second
heart sound.

^ [ Q: 1399 ] MRCPass - Cardiology

# A 50 year man presents with
lightheadness. He has frequent nonsustained
ventricular tachycardia on the ECG and cardiac
monitor. His bloods show a Hb 13.0 g/dl, WCC
7 x 10 9 /l_, platelets 230 x 10 9 /L, urea llmol/l,
creatinine 80pmol/l, sodium 134 mmol/I,
potassium 3.2 mmol/I, serum magnesium of
0.6 mmol/I (0.75).

Which one of the following is likely to be
responsible for his arrhythmias?

1- Poor diet

2- Alcoholism

3- Frusemide

4- Diarrhoea

5- Hyperphosphataemia

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Answer & Comments

Answer: 3- Frusemide

The likely cause of the arrhythmias is
hypomagnesaemia and hypokalaemia, which
is most commonly associated with diuretic
use.

[ Q: 1400 ] MRCPass - Cardiology

A 35 year old man presents with
chest pain to casualty following attendance at
a party. His friend reports that he has using
large doses of crack cocaine. His ECG shows ST
elevation of 4 mm in the anterior leads, and
he is managed as having acute myocardial
infarction. There is no previous cardiac
history.

Which of the following should be avoided?

1- GTN

valve replacement 8 months ago is admitted
with fevers, positive blood cultures and
suspected prosthetic valve endocarditis.

Which one of the following features suggests
worsening of the condition?

1- Paresthesiae

2- Vitiligo

3- Prosthetic valve click

4- Systolic flow murmur

5- Prolonged PR interval on the ECG

Answer & Comments

Answer: 5- Prolonged PR interval on the ECG

Infections of the prosthetic valve beyond 6
months after surgery are most often due to
Streptococcus viridans. Early infections are
usually due to Staphylococcus epidermidis

2- Aspirin

3- Diltiazem

4- Diamorphine

5- Atenolol

Answer & Comments

Answer: 5- Atenolol

The main effect of cocaine is inhibition of
noradrenaline and dopamine re-uptake in the
synaptic terminals. It is a potent
sympathomimetic agent, and causes a rise in
heart rate and blood pressure. It also causes
significant coronary artery spasm, and can
precipitate myocardial infarction which is
potentiated by the increase in myocardial
oxygen demand. Beta blockers such as
atenolol can precipitate worsening of the
coronary vasospasm and should be avoided.
Treatment is with nitrates or calcium channel
blockers (which are vasodilators).

(coagulase negative).

One of the major dangers with aortic valve
endocarditis is an aortic root abscess. This can
lead to prolonging of the PR interval by
erosion into the adjacent AV node, hence daily
ECGs are useful for monitoring.

[ Q: 1402 ] MRCPass - Cardiology

A 60 year old man has had an
anterior infarct. He hates to take medications
and agrees to have only one drug a day.

Which of the following drug classes has been
shown to have the maximal benefit in the peri-
infarct period?

1- Alpha blockers

2- Nitrates

3- Calcium Channel blockers

4- Beta blockers

5- Statin

[ Q: 1401 ] MRCPass - Cardiology
A 50 year old man who had a aortic

Answer & Comments

Answer: 4- Beta blockers

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Beta blockade has been shown to be
beneficial when started as soon as possible.
This was demonstrated in the ISIS-1 trial
where atenolol reduced mortality compared
to the control group at 1 year.

[ Q: 1403 ] MRCPass - Cardiology

A 20 year old man attends A+E
because of palpitations. Before they could do
an ECG his palpitations self terminated. The
ECG which was done showed sinus rhythm
with a PR interval of 70 ms.

What is the mechanism of the patient's
tachycardia?

1- Atrial flutter

2- Atrioventricular reentry tachycardia

3- Atrioventricular nodal reentry tachycardia

4- Ventricular tachycardia

5- Atrial tachycardia

Answer & Comments

Answer: 2- Atrioventricular reentry

tachycardia

The PR interval is short (<3 small squares or
<120 ms) suggesting wolff parkinson white
syndrome. There may be an accessory
pathway which predisposes to AVRT rather
than AVNRT.

[ Q: 1404 ] MRCPass - Cardiology

A 22 year old engineering student
presents with a history of breathlessness on
exertion and orthopnoea, fatigue and
anorexia.

On examination he has peripheral oedema, a
low volume pulse, elevated JVP with a rapid y
descent, no inspiratory increase in JVP, a quiet
praecordium and characteristic auscultatory
features of his condition. He also has
hepatomegaly and ascites.

ECG shows a widened QRS complex with
diffuse non-specific repolarisation changes.

What is the likely diagnosis?

1- Constrictive pericarditis

2- Cardiomyopathy

3- Congestive cardiac failure

4- Restrictive cardiomyopathy

5- Myocarditis

Answer & Comments

Answer: 4- Restrictive cardiomyopathy

The clinical radiological and ECG features
suggest the patient has a restrictive
cardiomyopathy. The characteristic
auscultatory feature of this condition is a
fourth heart sound reflecting increased atrial
contraction in an effort to overcome the
reduced compliance of the ventricle. A
pericardial knock would be a feature of
constrictive pericarditis, which has been ruled
out by the absence of Kussmaul's sign
(inspiratory increase in JVP) and absence of
pericardial calcification.

[ Q: 1405 ] MRCPass - Cardiology

A 42 year old man presents with a
regular narrow complex tachycardia of 160
bpm. Adenosine is considered by the duty
medical registrar.

Which of the following is a contraindication to
using iv adenosine?

1- Wolff parkinson white syndrome

2- Ventricular tachycardia

3- Asthma

4- Ischaemic heart disease

5- Gastric ulcer

Answer & Comments

Answer: 3- Asthma

Adenosine can produce profound
bronchospasm especially in asthmatics, and it
is contraindicated.

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[ Q: 1406 ] MRCPass - Cardiology

A 40 year old man is being assessed
for endocarditis according to Duke's criteria.

Which of the following is a major criteria for
diagnosing infective endocarditis?

1- Roth's spots

2- Vegetation seen on Echocardiogram

3- Splinter haemorrhages

4- Fever

Echocardiography shows asymmetric left
ventricular hypertrophy and systolic anterior
motion of the mitral valve.

The patient's symptoms may be treated with:

1- Ramipril

2- Frusemide

3- Aspririn

4- Atenolol

5- Digoxin

5- Glomerulonephritis

Answer & Comments

Answer: 2- Vegetation seen on

Echocardiogram

A definite diagnosis of endocarditis (Duke's
criteria) is achieved when 2 major criteria are
present, or 1 major and 3 minor criterias.

Major criteria:

blood culture positive for typical organisms

Answer & Comments

Answer: 4- Atenolol

The diagnosis is hypertrophic obstructive
cardiomyopathy as suggested by the signs of
jerky pulse, ejection systolic murmur and
echodardiographic findings. In these patients,
symptoms such as breathlessness is best
treated with (3-blockers and verapamil either
alone or in combination. Disopyramide is also
used second line.

persistent bacteremia
positive ECHO for vegetations
abscess or valve dehiscence
Minor criteria:

valvular heart disease or IV drug user

fever greater than 38°C

vasculitis

[ Q: 1408 ] MRCPass - Cardiology

A 50 year old man has a history of
myocardial infarction 6 months ago. He has
had 2 episodes of collapses and a 24 hour tape
shows episodes of non sustained VT. Coronary
angiography shows a 99% LAD artery stenosis
and angioplasty was unsuccessful due to the
tortuosity of the vessel. Echocardiography
shows a dilated LV at 5.9cm with an ejection
fraction of 30%.

skin lesions

Which is the most appropriate therapy?

suggestive ECHO (but not definite)
positive blood culture

[ Q: 1407 ] MRCPass - Cardiology

A 40 year old man presents with a
history of dyspnoea. On examination he has a
jerky carotid pulse, an ejection systolic
murmur is audible at the base of the heart and
a pan systolic murmur at the apex.

1- Amiodarone

2- Atenolol

3- Permanent pacemaker

4- Implantable cardiac defibrillator

5- Stem cell therapy

Answer & Comments

Answer: 4- Implantable cardiac defibrillator

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This patient satisfies two NICE guidelines for
ICD insertion. The first is an ejection fraction
of <30% with syncopal VT. The second is
syncopal VT following myocardial infarction.

The MADIT II trial showed that in patients with
a previous Ml and reduced left ventricular
ejection fraction (<30%), the prophylactic use
of an ICD, in addition to medications,
significantly reduced the risk of death.

The attending doctor decides to start digoxin.

Which one of these factors is most important
in taking into account the appropriate loading
dose of the drug?

1- Volume of distribution

2- Absorption

3- First pass metabolism

4- Creatinine clearance

[ Q: 1409 ] MRCPass - Cardiology

A 50 year old patient has tearing
interscapular chest pain. His ECG shows no ST
changes, but a CT scan with contrast showed
aortic dissection. His blood pressure is 140/70
mmHg.

Which is the most important management?

1- Intravenous labetalol

2- Ramipril

3- Refer for urgent cardiothoracic surgery

4- Echocardiography

5- Coronary angiogram

Answer & Comments

Answer: 1- Intravenous labetalol

Immediate management of aortic dissection is
aggressive blood pressure control.

Intravenous labetalol or sodium nitroprusside
can be used. Once this is done, the patient can
be further assessed with coronary
angiography or be referred for urgent surgery.

5- Patient weight

Answer & Comments

Answer: 4- Creatinine clearance

Digoxin is renally excreted. The plasma level of
the drug and its half life is dependent on the
volume of distribution and renal clearance. In
this example, the more important factor is
renal clearance. A lower loading dose should
be chosen in patients with renal impairment
and 6 hour post dose digoxin levels should be
measured.

[ Q: 1411 ] MRCPass - Cardiology

A 55 year old lady has dental phobia
but has finally gone to the dentist following
severe toothaches and is told she has dental
abscesses. She is brought into A+E with high
fevers by a relative. She is found to have a
diastolic murmur in the aortic area.

Which one of these is a sign of endocarditis?

1- Roslyn's Spot

2- Hepatomegaly

[ Q: 1410 ] MRCPass - Cardiology

A 40 year old man with previous
history of ischaemic heart disease and Type I
diabetes presents with heart rate of 150. His
ECG shows atrial fibrillation.

His blood tests show Hb 15 g/dl, WCC 10 x
10 9 /L, Platelets 280 x 10 9 /L, urea 13 pmol/l,
creatinine 160 pmol/l, sodium 138 mmol/l,
potassium 3.8 mmol/l.

3- Loss of peripheral pulses

4- Pulmonary fibrosis

5- Blood on urine dipstick

Answer & Comments

Answer: 5- Blood on urine dipstick

Blood on the urine dipstick indicates renal
vasculitis due to microemboli from

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vegetations in endocarditis. Osier's nodes are
small reddish tender areas on the pulp of
fingers or toes. Janew ay lesions are reddish
spots on fingers or toes, but are painless.
Splenomegaly occurs. Roth's spots are
vasculitic lesions ont he retina. Bouchard's
nodes occur in osteoarthritis.

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^ [ Q: 1412 ] MRCPass - Basic Science

/ - - -CL---

# A 30 year old patient develops
haemolytic anaemia, which is thought to be
due to penicillin treatment.

Which is the correct type of hypersensitivity
reaction to describe this?

Answer & Comments

Answer: 3- Duffy

Duffy negative patients are resistant to
developing plasmodium vivax infection. The
Duffy antigen receptor facilitates entry of
Plasmodium Vivax into red blood cells.

1- Type I

2- Type II

3- Type III

4- Type IV

5- Type V

[ Q: 1414 ] MRCPass - Basic Science

A 20 year old man has been new ly
diagnosed with Gaucher's Disease. This is
associated with a deficiency of which one of
the following enzymes?

Answer & Comments

Answer: 2- Type II

Drug induced haemolytic anaemia is due to a
type II hypersensitivity reaction. The types
are:

1- Glucocerebrosidase

2- Sphingomyelinase

3- Iduronidase

4- Hexosaminidase A

5- Arylsulphatase A

Type I - Anaphylaxis due to IgE from mast
cells and involving basophils

Type II - Cytotoxic due to free antibodies in
the circulation (usually IgG, IgM and IgA)
leading to cell lysis due to antigen-antibody
cross-linking and complement fixation

Type III - Immune complex deposition
associated with circulating IgG

Answer & Comments

Answer: 1- Glucocerebrosidase

Gaucher's disease is associated with the
enzyme glucocerebrosidase. As a result,
glucocerebroside accumulates, principally in
the phagocytic cells of the body but also
sometimes in the central nervous system
neurones.

Type IV - Cell-mediated due to interaction
between T cells and membrane-bound
antigens

[ Q: 1413 ] MRCPass - Basic Science

Which red blood cell antigen is
involved in entry of Plasmodium vivax into red
cells ?

1- Rhesus S

2- Rhesus D

3- Duffy

4- GP24

5- Kell

Three types of Gaucher disease are described.
Common to all three types are the presence
of hepatosplenomegaly and of large
glucocerebroside containing

reticuloendothelial histiocytes, or Gaucher
cells, in the bone marrow .

The other associations are:

Tay Sachs disease - Hexosaminidase A
deficiency

Niemann Pick disease - Sphingomyelinase
deficiency

Metachromatic leukodystrophy
Arylsulphatase A deficiency

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Hurler's syndrome - Iduronidase deficiency

[ Q: 1415 ] MRCPass - Basic Science

Which of the following diseases is X-
linked inherited?

1- Alpha 1 antitrypsin deficiency

2- Haemochromatosis

3- Marfan's syndrome

4- G6PD deficiency

5- Wilson's disease

Answer & Comments

Answer: 4- G6PD deficiency

cystathionine synthase results in
accumulation of homocysteine methionine.
Osteoporosis and osteopetrosis are also seen
in homocystinuria.

ATP Pi ♦ PPi

Vitamin

Cysteine

Metabolism of Homocysteine

G6PD deficiency's inheritance is X linked
recessive. Duchenne muscular dystrophy is
another example of a disease which has X
linked recessive inheritance. X linked
hypophosphataemic rickets is X linked
dominant.

[ Q: 1416 ] MRCPass - Basic Science

A 22 year old male who is tall and
thin, is found to have a high arched palate,
downw ard dislocation of lens, chest wall
deformities and livedo reticularis.

Which one of the following is also associated
with this syndrome?

1- Fibrillin gene defect

2- Positive Guthrie test

3- Autosomal Dominant inheritance

4- Osteopetrosis

5- Methionine accumulation

Answer & Comments

Answer: 5- Methionine accumulation

The diagnosis is homocystinuria (Marfan's
causes upw ards lens dislocation and fibrillin
gene defect). Homocystinuria is an autosomal
recessive disorder. Reduced activity of

[ Q: 1417 ] MRCPass - Basic Science
A postgraduate student is studying

HIV replication.

Which of the following is important in the
replication or transmission of HIV-1 ?

1- Trypsin

2- Bax

3- GP 120

4- P53

5- MHC

Answer & Comments

Answer: 3- GP 120

HIV reverse transcriptase, integrase and
protease are key enzymes essential for HIV
replication. The HIV genome contains the
genes: tat and rev along with nef, env, gag
and pol. The GP 120 is the major protein on
the surface of HIV that interacts with host
cells. HIV binds to cell surface CD4 but enters
cells through chemokine receptors including
CXCR4 and CCR5. Thymidine kinase is
produced by the herpes simplex virus.

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C134+ lymphocyte
or macrophage

[ Q: 1418 ] MRCPass - Basic Science

/ -

Which of the following anatomical
structures , if damaged , leads to choreiform
movement abnormalities?

1- Caudate nucleus

2- Subthalamic nucleus

3- Substantia nigra

4- Hippocampus

5- Corpus callosum

Answer & Comments

Answer: 1- Caudate nucleus

Caudate nucleus, putamen and globus
pallidus are areas within the basal ganglia
which, when impaired, can lead to choreiform
movements. Subthalamic nucleus lesion
causes hemiballismus. Hippocampus
involvement can cause memory loss.

[ Q: 1419 ] MRCPass - Basic Science

A 35 year old man presents with
bleeding oesophageal varices.

On examination he has Kayser- Fleischer rings
in the cornea. The inheritance of this disorder
is:

1- Polygenic inheritance

2- X-linked dominant

3- X-linked recessive

4- Autosomal recessive

5- Autosomal dominant

Answer & Comments

Answer: 4- Autosomal recessive

The diagnosis is Wilson's disease, which has
autosomal recessive inheritance.

Kayser Flescher Ring in Wilson's disease

[ Q: 1420 ] MRCPass - Basic Science

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Which of these is the correct description of

peptide bonds?

1- Bonds between 2 carboxylic acid groups of
amino acids

2- Hydrogen bonds between 2 side chains of
amino acids

3- Bonds between the carboxylic acid group
of one amino acid and the amino group of
the next

4- Bonds between alternating purine and
pyrimidine molecules

5- Covalent bonds between two amino acids

4- 10%

5- 5%

Answer & Comments

Answer: 4-10%

The virus can be found in other cell types
apart from hepatocytes, such as renal tubular
cells. 10% of patients with hepatitis B develop
chronic infection as compared to hepatitis C
where 80% develop chronic infection. The
likelihood of virus clearance increases with
better cell mediated immune responses.

Answer & Comments

Answer: 3- Bonds between the carboxylic acid
group of one amino acid and the amino group
of the next

^ [ Q: 1422 ] MRCPass - Basic Science

# A 25 year old man with cystic
fibrosis is referred for investigation of poor
fertility.

Peptide bonds are linkages between the
carboxylic acid (COOH) group of one amino
acid and the amino (NH2) group of the next
amino acid.

N-C-C

O H

N-C-C

\ /

OH H

H O H H

N-C-C-N-C—C

Peptide Bond

What is likely to have caused this?

1- Malabsorption and vitamin deficiency

2- Abnormal oestrogen metabolism

3- Acidification of seminal fluid

4- Hypopituitarism

5- Failure of development of vas deferens

Answer & Comments

Answer: 5- Failure of development of vas
deferens

Infertility in cystic fibrosis is due to
maldevelopment of vas deferens.

[ Q: 1421 ] MRCPass - Basic Science

A 45 year old man with a new
diagnosis of hepatitis B is keen to know more
about the prognosis of the disease.

What percentage of patients is likely to
develop chronic infection?

1 - 100 %

2- 80%

3- 50%

[ Q: 1423 ] MRCPass - Basic Science

A child has an endocrine condition
which has caused short stature.

Which of the following conditions may be
detectable by growth monitoring?

1- Thyrotoxicosis

2- Pseudohypoparathyroidism

3- Hypothyroidism

4- Insulin dependent diabetes mellitus

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5- XYY Syndrome

Answer & Comments

Answer: 3- Hypothyroidism

Growth monitoring can aid detection of the
following conditions:

1- None of the sons of an affected woman

2- Half of the daughters of an affected
woman

3- All of the sons of an affected woman

4- All children of an affected woman

5- All children of an affected man

hypothyroidism

growth hormone insufficiency

Turners & Noonan's syndrome, skeletal
dysplasias

coeliac disease, inflammatory bow el disease
intracranial tumours

[ Q: 1424 ] MRCPass - Basic Science

A 35 year old lady has psychogenic
diabetes insipidus. Her blood results show -
sodium 124 mmol/I; potassium 4.0 mmol/l;
Urea 5 mmol/l; Creatinine 30 mmol/l; Glucose
8 mmol/l.

What is the serum osmolality [mosmol/Kg]?

1- 255

2- 261

3- 264

4- 278

5- 284

Answer & Comments

Answer: 2- 261

Serum osmolality is 2 X sodium + Urea +
Glucose = 248 + 5 + 8 = 261 mOsmol/Kg.
Normal is 280 to 305 hence she has low
serum osmolality. An alternative formula is
1.9 x (Na + K) + Ur + Glucose.

[ Q: 1425 ] MRCPass - Basic Science

Which one of the following set of

offsprings would a X-linked dominant
condition be transmitted to?

Answer & Comments

Answer: 2- Half of the daughters of an
affected woman

The classical example of an X-linked dominant
inherited condition is familial
hypophosphataemic rickets. Remember to
differentiate between X linked recessive and
X linked dominant.

An affected woman has the chromosomes
XxX and will transmit this to half of her
daughters who will either have

XX or XxX chromosomes. Similarly, half of the
sons will have the disease XxY or XY
chromosomes.

Unaffected Affected Affected Unaffected

son daughter son daughter

X linked dominant inheritance with an
affected mother

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[ Q: 1426 ] MRCPass - Basic Science

Which one of these conditions is an
Autosomal Dominant disorder?

1- Ataxia Telangiectasia

2- Achondroplasia

3- Alkaptonuria

4- Cystic Fibtosis

5- Phenylketonuria

[ Q.: 1427 ] MRCPass - Basic Science
What is the effect of leptin on body

metabolism?

1- Decreases energy usage

2- Stimulates neuropeptide Y

3- Increases appetite

4- Stimulates pancreatic proteases

5- Reduces adipose tissue mass

Answer & Comments

Answer: 2- Achondroplasia

Answer & Comments

Answer 5- Reduces adipose tissue mass

The list of autosomal dominant disorders are:

■ achondroplasia

■ antithrombin III deficiency

■ Ehlers-Danlos syndrome

■ Familial hypercholesterolaemia
Gilbert's disease

■ hereditary haemorrhagic

telangiectasia

hereditary elliptocysis, hereditary

spherocytosis

Huntington's disease

■ idiopathic hypoparathyroidism

■ intestinal polyposis

■ marble bone disease

■ Marfan's syndrome

■ neurofibromatosis

■ polycystic kidney disease (adult)

■ protein C deficiency

■ osteogenesis imperfecta
Treacher Collins syndrome

■ tuberous sclerosis

Von Willebrand's disease

Leptin is expressed by adipocytes and
mediate effects via the hypothalamic centre
which controls hunger and energy
expenditure. It inhibits neuropeptide Y (which
is a potent appetite stimulator), increases
oxygen consumption, body temperature and
reduces adipose tissue mass.

Reproduction

Growth

-■PL

Hypothalamus
LRb

--E

Corticosteroids

Leptin
resistance

Metabolic rate.

th i TOld ' immune

sympathetic tone

I k

Leptin |

g Feeding

k Insulin
sensitivity

Adipocyte^v
Fat storage . 1

4 f

[ Q: 1428 ] MRCPass - Basic Science

A 65 year old man has a parietal
lobe infarct.

Which one of the following is a likely
manifestation?

1- Finger agnosia

2- Homonymous hemianopia

3- Bitemporal hemianopia

4- Expressive dysphasia

5- Dysdiadochokinesis

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Answer & Comments

Answer: 1- Finger agnosia
Parietal lobe signs are:

■ loss of two point discrimination
agraphia

■ finger agnosia
astereognosis

■ dyslexia
Gerstmann syndrome
receptive dysphasia

dressing and constructional dyspraxia

3- Metabolic acidosis with respiratory
compensation

4- Metabolic alkalosis with respiratory
compensation

5- Normal anion gap metabolic acidosis

Answer & Comments

Answer: 4- Metabolic alkalosis with

respiratory compensation

This patient is bulimic and has lost HCI from
excessive vomiting. She has metabolic
alkalosis which is compensated by
hypoventilation (hence low p02 and high
C02).

Gerstmann syndrome includes four features
(acalculia, agraphia, finger agnosia, left right
disorientation), and is due to a lesion in the
dominant hemisphere.

discriminate different fingers)

[ Q: 1429 ] MRCPass - Basic Science

An 18 year old ballet dancer
presents to A&E unwell. She has poor
dentition.

Her arterial pH is 7.44 and she has a pCCb of 6
kPa and p02 of lOkPa. Her chloride is 85 (95-
107) mmol/l, HCO3 is 30 (20-28) mmol/I.

Which of the following describes her acid base
balance?

1- Respiratory
compensation

acidosis

with

metabolic

2- Respiratory
compensation

alkalosis

with

metabolic

[ Q: 1430 ] MRCPass - Basic Science

Which one of following biochemical
abnormalities would be most commonly seen
in a diagnosis of Bartter's syndrome?

1- Hypochloraemia

2- Hyperkalemia

3- Hyponatraemia

4- Hypokalemia

5- Acidosis

Answer & Comments

Answer: 4- Hypokalemia

Bartter's syndrome is chracterised by:

hypokalaemic alkalosis, elevated renin and
aldosterone levels

[ Q: 1431 ] MRCPass - Basic Science

A man who has common variable
immunodeficiency comes to see the doctor in
the genetics clinic with his girlfriend. They
would like to start a family.

What is the probability that his children will
inherit his disease?

1 - < 10 %

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2- 25%

3- 50%

4- 75%

5- 100%

Answer & Comments

Answer: 1- <10%

Common Variable Immunodeficiency (CVID) is
a disorder characterized by low levels of
serum immunoglobulins and an increased
susceptibility to infections. A clear mode of
inheritance is not defined (there are multiple
modes) and hence there is a <10 % chance of
passing on the disease.

[ Q: 1432 ] MRCPass - Basic Science

fy -

m Transcription RNA (tRNA) has three

bases specific to a particular amino acid,
which it binds to messenger RNA (mRNA).

This specific area of tRNA known as:

1- Codon

2- Intron

3- Anticodon

4- Transposon

5- Exon

Answer & Comments

Answer: 3- Anticodon

Transfer RNA (tRNA) is a small RNA chain (74-
93 nucleotides) that transfers a specific amino
acid to a grow ing polypeptide chain at the
ribosomal site of protein synthesis during
translation. It has sites for amino-acid
attachment and codon (a particular sequence
of 3 bases) recognition. The codon
recognition is different for each tRNA and is
determined by the anticodon region, which
contains the complementary bases to the
ones encountered on the mRNA. Each tRNA
molecule binds only one type of amino acid,
but because the genetic code is degenerate,

more than one codon exists for each amino
acid.

Amino Acid — —

n n n n 3

tRNA

I 1 1 I 1 s 1 "1

- - H 5 n —I

Anticodon

Codon

5 '

3 1

mRNA

Anticodon and Codon

[ Q: 1433 ] MRCPass - Basic Science

Which one of these organelles have
DNA which can self replicate?

1- Golgi apparatus

2- Nuclear membrane

3- Mitochondria

4- Peroxisomes

5- Transcription factors

Answer & Comments

Answer: 3- Mitochondria

Only mitochondria have self replicating DNA

[ Q: 1434 ] MRCPass - Basic Science

A 25 year old woman was referred
for investigation of iron deficiency anaemia.
Her mother died aged 35 years from colonic
carcinoma and had Peutz Jegher syndrome.

Which is the likely mode of inheritance of
Peutz J eg hers syndrome?

1- Autosomal dominant

2- Autosomal recessive

3- X linked dominant

4- X linked recessive

5- Mitochondrial

Answer & Comments

Answer: 1- Autosomal dominant

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Peutz Jegher syndrome is an autosomal
dominant condition associated with
pigmentation, mainly, of the lips, buccal
mucosa, genitalia, hands and feet.

In addition, there are multiple
hamartogenous polyps of the gastrointestinal
tract - most often in the small bow el but may
occur affect any portion of the Gl tract.The
polyps themselves have a very low malignant
potential. About 10-20% of patients develop
gastrointestinal carcinoma, but there is also
increased risk of pancreatic, lung and breast
carcinoma.

Mucosal Pigmentation in Peutz Jegher

Syndrome

[ Q: 1435 ] MRCPass - Basic Science

The main histological abnormality in
Huntington's disease is seen in the:

1- Caudate lobe

2- Midbrain

3- Red nucleus

4- Inferior colliculus

5- Hippocampus

Answer & Comments

Answer: 1- Caudate lobe

The main histological abnormality in
Huntington's chorea is seen in the caudate
lobe and putamen where there is extensive
neuronal loss.

Caudate nucleus / lobe

[ Q: 1436 ] MRCPass - Basic Science

,_ At sympathetic nerve endings what

happens to the majority of amount of
noradrenaline following depolarisation ?

1- Reuptake by the nerve terminal ending

2- Breakdown by monoamine oxidase

3- Conversion to adrenaline

4- Stays at the nerve junction

5- Recycled by catechol-0 methyl transferase

Answer & Comments

Answer: 1- Reuptake by the nerve terminal
ending

Most noradrenaline is taken up back into
neurosecretory granules. MAO and COMT
metabolise NA in small amounts.

[ Q: 1437 ] MRCPass - Basic Science
A 62 year old man with epigastric

pains and weight loss is suspected of having
pancreatic carcinoma.

Which one of the following markers is useful?

1- Alpha feto protein

2- CA 19.9

3- CA 125

4- Prostate specific antigen

5- Carcinoembryonic antigen

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Answer & Comments

Answer: 2- CA 19.9

CA 19.9 is found in 70-90% of patients with
pancreatic carcinoma. CA125 and CEA may
also be positive but are less frequently so.

[ Q: 1438 ] MRCPass - Basic Science

The RET Proto-oncogene is
associated with which one of the following?

1- Insulinoma

2- Anaplastic thyroid carcinoma

3- Bronchial carcinoma

4- Medullary thyroid carcinoma

5- Pituitary tumour

^ [ Q: 1440 ] MRCPass - Basic Science

/ --—_ —L- 1 —

# A 62 year male presents with
bilateral neuropathic leg pains. There was
relevant past history of excess alcohol use. He
is currently on oral thiamine and omeprazole.
On examination, both knee reflexes are
reduced and there is reduced sensation to
fine touch in both feet.

What is the next best investigation to confirm
the diagnosis?

1- EMG

2- Chest X ray

3- CT head

4- CT spine

5- Blood sugar

Answer & Comments

Answer: 4- Medullary thyroid carcinoma

The RET proto-oncogene is associated with
multiple endocrine neoplasia MEN2A, MEN2B
and medullary thyroid carcinoma 1,
Hirschsprung disease.

Answer & Comments

Answer: 5- Blood sugar

The clinical features are consistent with a
diagnosis of peripheral neuropathy and
although he has another possible cause due
to alcohol, diabetes needs to be excluded.

[ Q: 1439 ] MRCPass - Basic Science

A young man presents with fevers
and has several blood tests.

Which one of the following, if increasedl
suggests infection?

1- Albumin

2- Transferrin

3- Ferritin

4- Alpha 2-macroglobulin

5- Leptin

Answer & Comments

Answer: 3- Ferritin

[ Q: 1441 ] MRCPass - Basic Science

A 65 year old Mediterranean man
who has leg cramps is started on quinine. He
presents 10 days later, with a history of
darkened urine, increasing breathlessness,
back pains and fatigue. Investigations show a
haemoglobin of 6.5 g/dl and raised
reticulocyte count.

Which of the following best explains this drug
reaction ?

1- Hereditary spherocytosis

2- Hereditary elliptocytosis

3- Autoimmune haemolytic anaemia

4- Pyruvate kinase deficiency

Ferritin is well known as an acute phase
protein which is increased in sepsis.

5- Glucose 6 phosphate dehydrogenase
deficiency

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Answer & Comments

Answer: 5- Glucose 6 phosphate

dehydrogenase deficiency

Glucose 6 phosphate dehydrogenase
deficiency (X linked recessive) is seen in
African, Mediterranean, Iraqi, Jew and South
East Asian Chinese people.

It predisposes to a haemolytic anaemia
reaction to drugs and infection. Implicated
drugs include aspirin, sulphonamides,
antimalarials and quinidine.

Blood film showing haemolysis in G6PD

deficiency

[ Q: 1443 ] MRCPass - Basic Science

# A 60 year old man has numbness
and tingling of the upper outer part of the left
thigh. On examination, there is sensory
impairment over the anterolateral aspect of
the thigh.

Where is the lesion?

1- Sacral nerve

2- Lateral cutaneous nerve of thigh

3- Pudendal nerve

4- Femoral nerve

5- Sciatic nerve

Answer & Comments

Answer: 2- Lateral cutaneous nerve of thigh

The diagnosis is meralgia paraesthetica, an
entrapment neuropathy of the lateral
cutaneous nerve of the thigh as it passes
under the inguinal ligament. Obesity is a risk
factor for the condition.

[ Q: 1442 ] MRCPass - Basic Science

A 40 year old female presents with a
movement disorder. There is a family history
of Huntington's chorea and the family is
worried that she may be developing this
condition.

What is its inheritance?

1- Autosomal recessive

2- Autosomal dominant

3- Mitochondrial inheritance

4- X linked recessive

5- X linked dominant

Answer & Comments

Answer: 2- Autosomal dominant

Huntington's chorea is inherited as an
autosomal dominant trait.

[ Q: 1444 ] MRCPass - Basic Science

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Which of the following haematological
disorders is inherited as an autosomal
recessive condition?

1- Acute intermittent porphyria

2- Antithrombin III deficiency

3- Pyruvate kinase deficiency

4- Glucose 6 phosphate dehydrogenase
deficiency

5- Protein C deficiency

Answer & Comments

Answer: 3- Pyruvate kinase deficiency

Pyruvate kinase deficiency is a rare congenital
haemolytic anaemia inherited as an
autosomal recessive manner.

The other condition's inheritance are:

■ Acute intermittent porphyria
autosomal dominant

■ Antithrombin 3 (AT3) - autosomal
dominant

Glucose 6 phosphate dehydrogenase
deficiency - X linked recessive

■ Protein C deficiency - autosomal
dominant

[ Q: 1445 ] MRCPass - Basic Science

A 22 year old lady has had several
episodes w heezing with associated flushing
of the face, lips and hand swelling over the
past few years.

What investigation should be done?

1- Cl esterase inhibitor level

2- Skin patch test with latex

Answer & Comments

Answer: 1- Cl esterase inhibitor level

Hereditary angioneurotic oedema is an
autosomal dominantly inherited condition
caused by a deficiency of Cl esterase
inhibitor. The main clinical feature is the
intermittent oedema in the skin around the
face, hands, feet, larynx and gastrointestinal
tract. Laryngeal oedema may cause wheezing.
The C2 and C4 level are low in between
attacks and C3 is normal. There are 2 varieties
of the disorder. Type I is most common and
results from an abnormally low level of
normal Cl-INH. Type II results from normal or
abnormally elevated levels of a dysfunctional
Cl-INH. In both types of the disease, initial
proteolytic components of the complement
cascade (eg, Clr, Cls) go relatively
unopposed and lead to the characteristic
presentation and laboratory abnormalities
(eg, low levels of C2 and C4).

Swollen lip in hereditary angioedema

[ Q: 1446 ] MRCPass - Basic Science

A 32 year old lady is admitted with a
history of epistaxis. Investigations reveal iron
deficiency anaemia. On examination, multiple
telangiectasia are noted around her lips and
in her mouth.

3- Skin prick test with latex

4- Serum ANCA

5- Rheumatoid factor

What is the mode of inheritance for the
condition?

1- Polygenic inheritance

2- Autosomal recessive

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3- Autosomal dominant

4- Autosomal dominant X-linked recessive

5- X-linked dominant

Answer & Comments

Answer: 3- Autosomal dominant

The patient has the features of hereditary
haemorrhagic telangiectasia (Osler-Rendu-
Weber syndrome) which has autosomal
dominant inheritance.

Hereditary haemorrhagic telangiectasia

The karyotype 46 XX, t (4;8)(q26;p21.3)
describes a female with a normal number of
chromosomes but a translocation between
the long arm of chromosome 4 (q) and the
short arm of chromosome 8 (p).

[ Q: 1448 ] MRCPass - Basic Science

A 28 year lady presents multiple
cafe au lait spots. A diagnosis of
neurofibromatosis type 1 made.

Which of the following is true regarding the
NF1 gene's inheritance and location?

1- Inherited in an autosomal recessive fashion

2- Inherited in an X linked fashion

3- Found on chromosome 17

4- Found in the mitochondrial genome

5- Is identical to the NF2 gene

7 \

[ Q: 1447 ] MRCPass - Basic Science

\fi

Which of the following statements

Answer & Comments

describes this karyotype 46 XX, t
(4;8)(q26;p21.3)?

1- Transversion between the long arm of
chromosome 4 (q) and the short arm of
chromosome 8 (p)

2- Transversion between the short arm of
chromosome 4 (q) and the short arm of
chromosome 8 (p)

3- Transversion between the long arm of
chromosome 4 (p) and the short arm of
chromosome 8 (q)

4- Translocation between the short arm of
chromosome 4 (q) and the long arm of
chromosome 8 (p)

5- Translocation between the long arm of
chromosome 4 (q) and the short arm of
chromosome 8 (p)

Answer & Comments

Answer: 5- Translocation between the long
arm of chromosome 4 (q) and the short arm
of chromosome 8 (p)

Answer: 3- Found on chromosome 17

Neurofibromatosis can be due to a defect of
either the NF1 or NF2 gene.

The NF1 gene is found on chromosome 17
inherited in an autosomal dominant fashion.

The NF2 gene is found on Chromosome 22.

[ Q: 1449 ] MRCPass - Basic Science

Regarding two loci A and B, which
are in linkage disequilibrium, which one of the
following statements is true?

1- The inheritance of an allele at A will almost
certainly exclude the inheritance of one of
the alleles at B

2- The degree of linkage disequilibrium can be
highly variable

3- The four alleles at A and B are inherited
independently provided that the
population is of sufficient size

4- The loci A and B are not linked

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5- It is a random association of alleles in a
breeding population

Answer & Comments

Answer: 2- The degree of linkage

disequilibrium can be highly variable

Linkage disequilibrium is a non-random
association of alleles in a breeding
population. The loci A and B are likely to be
linked. Hence inheritance of an allele A
usually occurs with the inheritance of allele B
(rather than excluded). The inheritance is still
dependent despite population size. Linkage
disequilibrium almost alw ays occurs between
alleles at genetic loci that are closely linked in
the genome. The degree of linkage
equilibrium can how ever, be highly variable.

^ [ Q: 1450 ] MRCPass - Basic Science

A ----

0 McArdle's disease is a genetic defect
in the phosphorylase enzyme, which affects
the breakdown of glycogen.

What is glycogen made up of?

1- Chains of glucose residues

2- Chains of fructose residues

3- Chains of sucrose residues

4- Chains of galactose residues

5- Chains of alternating galactose and glucose
residues

Answer & Comments

Answer: 1- Chains of glucose residues

The structure of glycogen consists of long
polymer chains of glucose units connected by
an alpha acetal linkage. Chains of glucose
residues are linked in glycogen by alpha 1,4-
glycosidic bonds (i.e. between the first carbon
atom Cl of one glucose and the fourth carbon
atom C4 of the next).

Glycogen - polymer of glucose molecules

[ Q: 1451 ] MRCPass - Basic Science

A patient with Angelman's
syndrome expresses genomic imprinting.

What does this mean?

1- That two genes are inherited together

2- That a gene is mitochondrially inherited

3- The severity of a disease worsens from
generation to generation

4- That one allele of a gene is not expressed

5- The differential expression of alleles is
dependent on their parental origin

Answer & Comments

Answer: 5- The differential expression of
alleles is dependent on their parental origin

Genomic imprinting is the term used to refer
to the differential expression of alleles
dependent on their parental origin.

An example is when the same gene having
different phenotypic expression is due to
either maternal inheritance (e.g. Prader-Willi
syndrome) or due to paternal inheritance
(e.g. Angelman's syndrome).

Genomic Imprinting - the same gene has
different phenotypic expression depending
on w hether it is maternally or paternally

inherited

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^ [ Q: 1452 ] MRCPass - Basic Science

A ■---

# A 25 year old patient with acquired
Factor VIII deficiency was given a monoclonal
antibody drug following an episode of severe
bleeding.

Which one of these is the likely drug?

1- Prednisolone

2- Cyclosporin

3- Enoxaparin

4- Rituximab

5- Cyclophosphamide

Answer & Comments

Answer: 4- Rituximab

Rituximab is a chimeric, human IgGl
monoclonal antibody specific for the CD20
antigen expressed on the surface of B
lymphocytes. The antibody is known to
induce rapid in vivo depletion of both normal
B lymphocytes and lymphoma B cells. The
drug's limited toxicity has led to the recent
use of rituximab for the treatment of
autoimmune disorders, anticipating a
decrease in antibody production by CD20+ B
cells. Examples include ITP, autoimmune
hemolytic anaemia, and acquired hemophilia
A (factor VIII deficiency).

Monoclonal antibodies are made by fusing a
mouse B cell with myeloma cell line.
Antibodies can be purified and cell lines are
grown in vitro. The antibodies can be used to
measure hormone levels with immunoassays.

Tumor cells ere injected into a mouse to
stimluate production of B cells , which produce
different types of antitumor antibodies.

2. Immortalized
myeloma cells
are collected.

Myeloma cell

Hybrid

4. The hybrid cell that
produces the needed
antibody is selected
and cloned to produce
unlimited quantities of
a monoclonal antibody.

3. The B cells are fused
with the myeloma cells
to produce immortalized,
antibody-producing
hybrid cells.

Producing Monoclonal Antibodies

[ Q: 1453 ] MRCPass - Basic Science

A 55 year old carpenter has pain in
his shoulder. On examination, there was pain
during resistance of abduction.

Which muscle is likely to be involved?

1- Infraspinatus

2- Supraspinatus

3- Pectoralis major

4- Teres minor

5- Latissimus dorsi

Answer & Comments

Answer: 2- Supraspinatus

Supraspinatus tendonitis is also known as
rotator cuff syndrome. Supraspinatus
tendinitis typically affects patients between
40 and 60 years of age following prolonged or
excessive use of the shoulder. Pain is usually
more severe but of shorter duration in
younger patients due to a more vigorous
repair process. Pain is felt in the shoulder and
over the deltoid muscle but there is no
obvious outw ard sign of inflammation or
swelling. There is pain on active or resisted
abduction.

[ Q: 1454 ] MRCPass - Basic Science
A 25 year old man has the condition

ME LAS.

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Which one of the following is a feature of the
disease?

1- Cardiac arrhythmia

2- Colour blindness

3- Hirsutism

4- Lactic acidosis

Answer & Comments

Answer: 5- Musculocutaneous nerve

The musculocutaneous nerve suppleis the
biceps, coracobrachialis and brachialis
muscles. It also supplies sensation over the
lateral aspect of the forearm.

5- Ketoacidosis

Answer & Comments

Answer: 4- Lactic acidosis

Mitochondrial disorders such as MELAS
(Mitochondrial myopathy, encephalopathy,
lactic acidosis, stroke) and MERRF have
muscle, brain, nerve and pancreatic
involvement. With pancreatic and muscle
involvement, diabetes and lactic acidosis can
occur, but ketoacidosis is infrequent.

Scattered abnormal, vacuolated fibers with
clear rim in MELAS: H & E stain

[ Q: 1455 ] MRCPass - Basic Science

Which nerve lesion causes weakness
of biceps, coraco-brachialis and brachialis and
sensory loss over the lateral aspect of the
forearm ?

1- Radial nerve

2- Brachial nerve root

3- Axillary nerve

4- C5 and C6 root

5- Musculocutaneous nerve

Musculocutaneous Nerve

formed from lateral
cord of brachial plexus

pierces coracobrachialis
then lies between biceps
and brachialis

becomes lateral cutaneous
nerve of forearm at elbow

[ Q: 1456 ] MRCPass - Basic Science

A 35 year old male presents with
oral and genital mucocutaneous ulcerations.
He also has associated polyarthritis affecting
the lower limbs. He is currently on an recent
episode of pulmonary embolism.

Which of the genetic association is common
with such a presentation?

1- HLA A3

2- HLADR2

3- HLADR3

4- HLA B27

5- HLA B5

Answer & Comments

Answer: 5- HLA B5

The features of genital and oral ulceration, as
well as prothrombotic states are consistent
with Behcet's disease. Familial occurrence has
been reported and it seems to occur in

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patients from eastern Mediterranean
countries and Japan. The disease appears to
be linked to HLA-B5, HLA -B51 and HLA-DR5
alleles.

[ Q: 1458 ] MRCPass - Basic Science

Which of the following anatomical
structures is likely to cause chorea , if
damaged?

1- Hippocampus

2- Subthalamic nucleus

3- Thalamus

4- Caudate nucleus

5- Substantia nigra

Answer & Comments

Answer: 4- Caudate nucleus

Damage to the caudate nucleus is most likely
to cause chorea. This is involved in
Huntington's chorea.

Oral Ulceration in Behcet's Disease

[ Q: 1457 ] MRCPass - Basic Science

A 65 year old man was admitted
with an exacerbation of chronic obstructive
pulmonary disease.

His arterial blood gases on air showed pH
7.29, paC0 2 8.5 kPa, pa0 2 8.0 kPa, and
standard bicarbonate 30.5 mmol/l.

What is the acid-base disturbance?

VL nucleus of
thalamus

Basal ganglia
and associated
structures

Caudate

nucleus

Putamen

Substantia

nigra

Globus

patlidus

Subthalamic

nucleus

Striatum

1- Metabolic alkalosis

2- High anion gap metabolic acidosis

3- Normal anion gap metabolic acidosis

4- Respiratory alkalosis

5- Respiratory acidosis

Answer & Comments

Answer: 5- Respiratory acidosis

This patient had an acidosis with a high
PaC02 and normal standard bicarbonate-
respiratory acidosis. This is a common finding
in acute exacerbations of chronic obstructive
pulmonary disease, especially with type II
respiratory failure.

[ Q: 1459 ] MRCPass - Basic Science

A 60 year old woman has
hyponatraemia. Following investigation, she
was diagnosed as having SIADH.

Which of the following is the most likely
cause?

1- Ramipril

2- Ibuprofen

3- Chlorpromazine

4- Alcohol

5- Atenolol

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Answer & Comments

Answer: 3- Chlorpromazine

SIADH can be caused by many drugs
(mnemonic starting with C) - carbamazepine,
chlorpropramide, cyclophosphamide,

chlorpromazine and clomipramine (i.e.
neuroleptics and antidepressants including
SSRIs). Alcohol decreases ADH release.

[ Q: 1460 ] MRCPass - Basic Science

A 40 year old diabetic patient
overdosed on 30 tablets of an unknown
medication.

She has blood gases showing a pH of 7.32,
p0 2 of 16 kPa and pC0 2 of 3 kPa. Her HC0 3 is
8 mmol/I and base excess is -5.

What is the likely scenario?

ankle jerk. She also had sensory loss over the
lateral aspect of her ankle.

Which of these nerve lesions is likely?

1- Deep peroneal nerve

2- Femoral nerve

3- Sciatic nerve

4- Lumbosacral plexus

5- Inferior gluteal nerve

Answer & Comments

Answer: 3- Sciatic nerve

The sciatic nerve branches into the tibial
nerve and common peroneal nerve. Damage
to these branches will cause almost total
weakness around the ankle and absent ankle
jerk.

1- Metabolic acidosis with respiratory

compensation

2- Metabolic alkalosis with respiratory

compensation

3- Respiratory acidosis with metabolic

compensation

4- Respiratory alkalosis with metabolic

compensation

5- Normal anion gap metabolic acidosis

Answer & Comments

Answer: 1- Metabolic acidosis with

respiratory compensation

The patient is likely to have overdosed on
metformin and has metabolic acidosis. The
pH is acidotic and she is hyperventilating for
respiratory compensation of acid base
balance, hence the low C02 and high 02

[ Q: 1461 ] MRCPass - Basic Science

A 50 year old lady has pain in her
right leg. On examination, there was
weakness of her right ankle and absent right

[ Q: 1462 ] MRCPass - Basic Science

Which form of nerve damage leads
to complete inability to raise the arm at the
shoulder with sensory loss over the deltoid ?

1- Lateral cutaneous nerve

2- Axillary nerve

3- Radial nerve in the axilla

4- Suprascapular nerve

5- C5 and C6 of the brachial nerve plexus

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Answer & Comments

Typical examples are :

Answer: 2- Axillary nerve

The axillary nerve supplies the deltoid and
teres minor as well as the skin over the
deltoid.

AXILLARY

Oeaoti. prxxje titers

Deltoid trrlonof fitwft

Anterior brands

posterior fibers

Posaenor oraocr

rmnor

[ Q: 1463 ] MRCPass - Basic Science

A 40 year old man presented 2 years
ago with an inherited neurological disorder
causing weakness. His father developed the
disease in his 70s and his daughter was born
5 years ago with a severe form of the
condition. His mother, sister, wife and son are
unaffected.

What is the likely mode of inheritance?

1- Autosomal dominant

2- Autosomal recessive

Huntington's disease, myotonic dystrohpy,
fragile X syndrome & Friedriech's ataxia.

[ Q: 1464 ] MRCPass - Basic Science

A 20 year old patient has been
kicked in the shin during an aggressive
football match. He is unable to evert his foot
and dorsiflex his ankle.

Which nerve is injured?

1- Femoral nerve

2- Saphenous nerve

3- Gluteal nerve

4- Common peroneal nerve

5- Anterior tibial nerve

Answer & Comments

Answer: 4- Common peroneal nerve

The peroneal muscles around the lateral part
of the shin help to dorsiflex the ankle, extend
the toes and evert the foot. They are supplied
by the common peroneal nerve. The common
peroneal nerve is a branch of the sciatic
nerve. The manner in which the common
peroneal nerve snakes around the fibular
head exposes it to injury.

3- X linked inheritance

4- Trinucleotide repeat disease

5- Mitochondrial inheritance

Answer & Comments

Answer: 4- Trinucleotide repeat disease

[ Q: 1465 ] MRCPass - Basic Science

A 10 year old boy with blue sclerae
and recurrent fractures has been diagnosed
with Osteogenesis imperfecta.

What abnormality predisposes to bone
fragility?

The inheritance showing increasing disease
severity with earlier onset of disease in
subsequent generations is called anticipation.
This is typical of trinucleotide repeat disease
where there is expansion of repetitive
sequence of three nucleotides with each
generation.

1- Metalloproteinase

2- Type 1 collagen

3- Fibronectin

4- Laminin

5- Elastin

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Answer & Comments

Answer: 2- Type 1 collagen

Osteogenesis imperfecta (01) is a condition
resulting from abnormality in the type I
collagen, which most commonly manifests as
fragility of bones.

[ Q: 1466 ] MRCPass - Basic Science

A 65 year old man has familial
hypercholesterolaemia.

Which one of the following is a characteristic
feature of the condition?

1- Palmar xanthomas

2- Autosomal recessive inheritance

3- Reduced expression of LDL receptors

4- Hypertriglyceridaemia

5- Elevated chylomicrons

Answer & Comments

Answer: 3- Reduced expression of LDL
receptors

The characteristics of familial
hypercholesterolaemia are:

■ autosomal dominant condition

■ increased LDL concentrations

■ reduced HDL concentrations

■ reduced numbers of LDL receptor

■ cardiovascular disease
tendon xanthomatas

[ Q: 1467 ] MRCPass - Basic Science

A 65 year old man has a right sided
homonymous hemianopia and right sided
upper and lower limb weakness. His reflexes
are brisk on the right side. There is no sensory
abnormalities.

Which of the following area could be
infarcted?

1- Left temporal

2- Left parietal

3- Left cingulate gyrus

4- Right medial thalamus

5- Left frontal lobe

Answer & Comments

Answer: 2- Left parietal

The cingulate gyrus forms part of the limbic
system, which is associated with mood and
emotions. Frontal lobe lesions are not usually
associated with homonymous hemianopia

[ Q: 1468 ] MRCPass - Basic Science

A 50 year old woman has right sided
weakness, headache and vomiting. On
examination she has a hemiplegia affecting
the right face, arm and leg. She also has
unilateral internuclear ophthalmoplegia with
failure of adduction to the left and nystagmus
to the left. Fundoscopy reveals papilloedema.

In this patient , the papilloedema is due to
obstruction at:

1- The foramen of Monro

2- The foramen of Morgagni

3- The foramen of Magendie

4- The aqueduct of Sylvius

5- The foramen of Luschka

Answer & Comments

Answer: 4- The aqueduct of Sylvius

The aqueduct of the midbrain (the aqueduct
of Sylvius) runs in the tegmentum of the
midbrain and joins the third and fourth
ventricles. Compression of the aqueduct can
result in obstructive hydrocephalus and
papilloedema.

Headache and vomiting can occur because of
raised intracranial pressure. Malignant or
benign intracranial tumors, colloidal cysts,

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arachnoid cysts, and neurocysticercosis can
also cause compression and need to be ruled
out.

Lateral Ventricles

Choroid Plexus

* , ' \Aqueduct of Sylvius

3^//— Fourth Ventricle

Foramen of Luschka

CSF drainage

[ Q: 1469 ] MRCPass - Basic Science

A 75 year old man has a posterior
cerebral artery territory infarct.

Which one of the following is likey to occur?

> = posterior
communicating A

Posterior Cerebral Artery

Foramen of Magendie

[ Q: 1470 ] MRCPass - Basic Science

A 30 year old lady has palpitations

and is subsequently confirmed to have
thyrotoxicosis due to Grave's disease.

Which of the following statements is true?

1- Grave's disease is associated with muscular
dystrophy

1- Bitemporal hemianopia

2- Expressive dysphasia

3- Receptive dysphasia

2- Propylthiouracil is preferred over
carbimazole in pregnancy

3- Radioactive iodine always improves Grave's
disease

4- Colour blindness

5- Cortical blindness

Answer & Comments

Answer: 5- Cortical blindness

4- Smoking history is irrelevant

5- Steroid eye drops are typically used to
treat Grave's eye disease

Answer & Comments

The posterior cerebral artery supplies the
occipital lobe and the inferior portion of
temporal lobe. Homonymous hemianopia,
cortical blindness, verbal dyslexia and
hemivisual neglect can occur.

Answer: 2- Propylthiouracil is preferred over
carbimazole in pregnancy

Grave's disease is associated with other
autoimmune conditions e.g. myasthenia
gravis.

Propylthiouracil is preferred to Carbimazole
in pregnancy because carbimazole crosses the
placenta and can cause nail/finger
abnormalities (aplasia cutis) in the baby.

Radioactive iodine can worsen Grave's
disease. Smoking is a risk factor for Grave's
disease.

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High dose oral or iv steroids are required in
Grave's eye disease.

[ Q: 1471 ] MRCPass - Basic Science

Which one of the following
conditions has autosomal dominant

inheritance?

1- Oculocutaneous albinism

2- Betathalassaemia

3- Marfan's syndrome

4- Wilson's disease

5- Xeroderma Pigmentosa

1- DAF

2- CR1

3- C3b

4- Factor I

5- MCP

Answer & Comments

Answer: 3- C3b

C3b is an active fragment of C3, and can
activate the alternative pathw ay. DAF, CR1,
Factor I and MCP are complement pathway
inhibitors.

Answer & Comments

7 )

[ Q: 1473 ] MRCPass - Basic Science

Answer: 3- Marfan's svndrome

The thymus gland contains 3 major

Marfan's syndrome inheritance is autosomal
dominant. The rest of the conditions are
autosomal recessive.

The list of autosomal recessive conditions are:

oculocutaneous albinism
alkaptonuria
Bartter's syndrome
cystic fibrosis

endemic goitrous cretinism
galactosaemia
Gaucher's disease

cell populations-epithelial, hemopoietic, and
accessory cells.

Which of the following cells develop in the
thymus?

1- Macrophages

2- T cells

3- Erythrocytes

4- B cells

5- Hairy cells

Answer & Comments

Answer: 2- T cells

glycogen storage disease
phenylketonuria
Wilson's disease
xeroderma pigmentosa

[ Q: 1472 ] MRCPass - Basic Science

Activation of the complement
components is associated with potent
biological functions to counteract infections.

B cells are not only produced in the bone
marrow but also mature there. How ever, the
precursors of T cells leave the bone marrow
and mature in the thymus.

[ Q: 1474 ] MRCPass - Basic Science

A 55 year old male has been a heavy
smoker and has had previous exposure to
silica dust. He presents to A&E with
worsening longstanding breathlessness.

Which of the following activates rather than
inhibits the complement pathw ay?

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His arterial pH is 7.36. pC0 2 of 7.7 kPa and
p0 2 of 7.7kPa. His HCO3 is 32 (20-28) mmol/l
and Base excess is 2.

Which is the accurate description of his acid
base balance?

1- Metabolic acidosis with respiratory

compensation

2- Metabolic alkalosis with respiratory

compensation

3- Respiratory acidosis with metabolic

compensation

4- Respiratory alkalosis with metabolic

compensation

5- Normal anion gap metabolic acidosis

Answer & Comments

Answer: 3- Respiratory acidosis with
metabolic compensation

There is chronic type 2 respiratory failure
causing respiratory acidosis because of the
hypoxia and hypercapnia. This is
compensated metabolically by HC03
retention and pH is restored to within a
normal range.

[ Q: 1475 ] MRCPass - Basic Science

Which is the structure formed by the
roots of the lumbar and sacral nerves?

1- Falx cerebri

2- Amygdala

Cord

Conus
medularis - -

Cauda

equina

[ Q: 1476 ] MRCPass - Basic Science

A 40 year old woman has MELAS.

Which of the following is correct regarding
the risk of the grandsons and granddaughters
having the disease?

1- Son's children 100%, Daughter's children
100 %

2- Son's children 0%, Daughter's children
100 %

3- Son's children 50%, Daughter's children
100 %

4- Son's daughters 100%, Son's sons 100%

5- Daughter's daughters 100%, Daughter's
sons 0%

Answer & Comments

Answer: 2- Son's children 0%, Daughter's
children 100%

3- Cisterns

4- Medulla oblongata

5- Cauda equina

Answer & Comments

Answer: 5- Cauda equina

The cord is tapered at the lower end to form
the conus medullaris.

The roots of the lumbar and sacral nerves are
long and they form the cauda equina.

Kearn Sayre's, MELAS, MERRF, progressive
external opthalmoplegia, Leber's optic
atrophy are mitochondrially inherited
diseases. The mitochondrial DNA is passed on
only from the mother to all children.

[ Q: 1477 ] MRCPass - Basic Science

A 35 year old lady presents with w
asting of the quadriceps and weakness of
knee extension. There is loss of the knee jerk
and sensory impairment over the front of the

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thigh and over the subcutaneous surface of
the tibia.

The likely lesion is:

1- Peroneal nerve

2- Brachial nerve

3- Obturator nerve

4- Femoral nerve

5- Sacral nerve

Lisch Nodules

Answer & Comments

Answer: 4- Femoral nerve

The femoral nerve supplies the iliacus and
pectineus, and the muscles on the anterior
thigh. The nerve also provides cutaneous
filaments to the front and inner side of the
thigh and to the leg and foot (via saphenous
nerve).

^ [ Q: 1479 ] MRCPass - Basic Science

fi -

A 17 year old lady has small, raised
lesions on her trunk and also has axillary
freckles.

What is the likely mode of inheritance of this
condition?

1- Autosomal dominant

2- Autosomal recessive

[ Q: 1478 ] MRCPass - Basic Science

Which one of the following features
is found in Neurofibromatosis Type 1 (NF1)?

1- Webbed neck

2- Calcinosis

3- Lens dislocation

4- Lisch Nodules

5- Roths spots

Answer & Comments

Answer: 4- Lisch Nodules

Lisch nodules (pigmented spots) of the iris are
present in more than 90% of patients with
neurofibromatosis type 1. Bilateral acoustic
neuromas are a hallmark feature of
neurofibromatosis type 2.

The diagnosis is suggested by six or more cafe
au lait spots. Although the condition is
autosomal dominant, almost half of all cases
are new mutations.

3- Trinucleotide repeats

4- X linked recessive

5- X linked dominant

Answer & Comments

Answer: 1- Autosomal dominant

The condition described is neurofibromatosis.
Inheritance is autosomal dominant.

The gene defect for NF-1 is on chromosome
17, and for NF-2 is on chromosome 22.

Neurofibromas

[ Q: 1480 ] MRCPass - Basic Science

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A 35 year old diabetic man has loss of
sensation in the anterior and lateral part of
the thigh.

Which nerve is likely to be affected?

1- Sciatic nerve

2- Lateral cutaneous nerve

1- Phosphofructokinase

2- Glucokinase

3- Hexokinase

4- Fructokinase

5- Glucose 6 phosphatase

3- Gluteal nerve

4- Pudendal nerve

5- Femoral nerve

Answer & Comments

Answer: 2- Lateral cutaneous nerve

Trauma around the inguinal ligament can lead
to damage in the lateral cutaneous nerve
supplying the anterolateral portion of the
thigh. It is a purely sensory nerve which
travels lateral to the psoas muscle.

Lateral Cutaenous Nerve (marked NCL)

[ Q: 1481 ] MRCPass - Basic Science

Which of the following enzymes
converts glucose to glucose-6-phosphote?

Answer & Comments

Answer: 3- Hexokinase

Hexokinase catalyses the conversion of
glucose to glucose-6-phosphate, using a
phosphate group donated from ATP.

[ Q: 1482 ] MRCPass - Basic Science

Which of the following is true
regarding the role of restriction enzymes?

1- Anneal DNA together

2- Synthesize DNA

3- Are involved in the cell cycle arrest

4- Cut DNA

5- Degrade DNA

Answer & Comments

Answer: 4- Cut DNA

Restriction enzymes cut DNA at nucleotide
sequences specific to each restriction
enzyme.

Hindlll and EcoRI are examples of restriction
enzymes. DNA ligase and polymerase are
involved in joining and linking DNA together.

EcoRI as an example of a restriction enzyme

[ Q: 1483 ] MRCPass - Basic Science

Respiratory distress syndrome can
be associated with reduction of lung
surfactant. Surfactant is produced in which
cell in the lung?

1- Alveoli white cells

2- Vessel endothelium

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3- Type II pneumocyte

4- Small cell

5- Keratinocytes

Sensory loss occurs over the lateral three and
a half digits of the hand and the lateral aspect
of the palm. There may also be vasomotor
and trophic changes.

Answer & Comments

Answer: 3- Type II pneumocyte

Lung surfactant is produced by type II
pneumocytes.

[ Q: 1484 ] MRCPass - Basic Science

A 22 year old cricket player presents
with an injury to his right upper limb. On
examination of the right upper limb there is
incomplete and defective pronation. The
wrist flexors are paralysed when examined
against resistance.

When this is tested the tendon of flexor carpi
ulnaris stands out and the hand becomes
ulnar deviated. Flexion of the ulnar Two
fingers is possible although it is w eaker than
normal. Abduction and opposition of the
thumb is defective. There is sensory loss over
the lateral three and a half digits of the hand
and the lateral aspect of the palm.

The injury is located at:

1- Ulnar nerve at the wrist

2- Ulnar nerve at the elbow

3- Brachial nerve

4- Musculocutaneous nerve

5- Median nerve at the elbow

Answer & Comments

Answer: 5- Median nerve at the elbow

An injury to the median nerve at the elbow
causes weakness of pronator teres, radial
flexors of the wrist, the long finger flexors
except the ulnar half of the deep flexors,
most of the muscles of the thenar eminence
and the Two radial lumbricals.

median

nerve

1 brrnthe to pronator to :tf ,
pdmm$ longus ,flox. c up .rod.,
flex.dig profundnu

2 p (i riaiti niaro * s eoui

3. median nm r t lying 1) rtuwi
flex dig. nip. and profundnu.

4. palmar cuianeoiu brrnch

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flex.pol.bredid., ifad.pol.farwu.
opponau pollicu

7 farm the* to medial himJmc ifa
phu cutaneous to three and one
half digits

[ Q: 1485 ] MRCPass - Basic Science

Which of the following is true
regarding autosomal recessive inheritance
involving parents and children?

1- For parents with one affected child, the risk
of having another affected child is 1 in 2

2- For parents with one affected child, the risk
of having another affected child is 1 in 8

3- Unaffected siblings of an affected child
have a 1 in 3 chance of being carriers

4- Unaffected siblings of an affected child
have a 2 in 3 chance of being carriers

5- Unaffected siblings of an affected child are
definite carriers

Answer & Comments

Answer: 4- Unaffected siblings of an affected
child have a 2 in 3 chance of being carriers

The best way to understand is to draw a
family tree with the parents both being
carriers of the recessive gene [AAx and BBx]
and four possible inherited combinations [
AB, AxB, AxB and AxBx].

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For parents with one affected child, the risk
of having another affected child is 1 in 4.

Unaffected siblings have a 2 in 3 chance of
being carriers because the last possibility of
both recessive genes is eliminated (AxBx).

Bacterium

[ Q: 1486 ] MRCPass - Basic Science

Which ONE of the following
organelles have self replicating DNA ?

1- Endoplasmic Reticulum

2- Golgi apparatus

3- Peroxisome

4- Mitochondria

5- Lysosomes

Answer & Comments

Answer: 4- Mitochondria

Mitochondria have DNA, which can pass on
inherited mitochondrial diseases (e.g. MELAS
/ MERRF ).

[ Q: 1487 ] MRCPass - Basic Science
A Plasmid best described as

1- A recombinant section of DNA

2- Bacterial DNA separate from chromosome

3- Multiple origins of replication

4- Viral RNA

5- Consist of multiple copies of a single gene

Answer & Comments

Answer: 2- Bacterial DNA separate from
chromosome

Plasmids are circular molecules of bacterial
DNA separate from the bacterial
chromosome. They are usually small,
consisting of a few thousand base pairs. They
carry one of a few genes and have a single
origin of replication.

[ Q: 1488 ] MRCPass - Basic Science

A 30 year old man has Lipoprotein
lipase deficiency.

Which one of the following features is most
likely?

1- Marked hypercholesterolaemia

2- Reduced chylomicrons

3- Marked hypertriglyceridaemia

4- Familial Hypercholesterolaemia

5- Combined hyperlipidaemia

Answer & Comments

Answer: 3- Marked hypertriglyceridaemia

Mutations in the LPL gene cause familial
lipoprotein lipase deficiency.

The breakdown of chylomicrons releases fat
molecules for storage in fat (adipose) cells or
for energy use.

Inheritance is autosomal recessive. The
breakdown of chylomicrons releases
triclyceride molecules for storage in adipose
cells or for energy use. Mutations in the LPL
gene prevent lipoprotein lipase from breaking
down chylomicrons effectively, leading to
high triglyceride levels in the plasma.

[ Q: 1489 ] MRCPass - Basic Science

Which one of the following is true
regarding mitochondrial DNA diseases?

1- Mitochondrial DNA is inherited from the
father

2- Mitochondrial DNA is composed of a
circular loop of doublestranded DNA

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3- Mitochondrial genome encodes for nuclear
proteins

4- Mutations of mitochondrial DNA occurs in
multiple sclerosis related optic atrophy

5- Simvastatin depletes muscle mitochondrial
DNA

Answer & Comments

Answer: 2- Mitochondrial DNA is composed of
a circular loop of doublestranded DNA

Mitochondrial DNA is inherited from the
mother. Mitochondrial DNA codes for
proteins in the oxidative phosphorylation /
electron transport chain. Leber's optic
atrophy is a form of mitochondrial disease.
AZT (zidovudine) is an example of a drug
which does deplete muscle mitochondrial
DNA.

Mitochondrial DNA

control region

rtf NA

cytochrome b

vj&urwts of HA0H
dchydroonas*

MitHjMts of cytochrome c
/ otklif* \.

MfftRF

#344

KARP

8993

LHON

3460

14484

. m s

14459

Mf.AS

3?4 3

. HON

11771

ADPO
4 336

Trafttfer RNA < —

Mitochondrial DNA

[ Q: 1490 ] MRCPass - Basic Science

Which of the following is degraded
to uric acid?

1- Uracil

2- Thymine

3- Cytosine

4- Guanine

5- Orotic acid

Answer & Comments

Answer: 4- Guanine

The purine bases adenine and guanine are
degraded to uric acid. Adenosine and
Xanthine are also metabolised to uric acid.
Uracil, thymine, cytosine and orotic acid are
pyrimidine bases.

"do novo" synthesis

PRPP

* ©

SAICAR -► SAICAnbosxJe

Furr

AICAH

S AMP — S Ado

\®/ oV um

Xanthine

Unc ac»d

Purine Metabolism

[ Q: 1491 ] MRCPass - Basic Science

Which one of the following features
does trinucleotide repeat disorders exhibit?

1- Anticipation

2- Linkage

3- Methylation

4- Reduction

5- Genomic imprinting

Answer & Comments

Answer: 1- Anticipation

Trinucleotide repeat disorders typically
worsen if there are expansion in the numbers
of repeats. This is labeled anticipation. The
repeats may be involved in coding sequences
of proteins e.g. in Huntington's. Fragile X
syndrome causes cognitive impairment.

[ Q: 1492 ] MRCPass - Basic Science
A 35 year old patient has a high

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arched palate and aortic regurgitation. He has
a tall stature, and upw ards lens dislocation.

Which gene abnormality does he have?

1- Myosin

2- Actin

3- Fibrillin

4- Spectrin

5- Ankyrin

Answer & Comments

Answer: 3- Fibrillin

In Marfan's syndrome, a mutation in a gene
causes a defect in the body's production of
fibrillin, an important building block of
connective tissue. In many families with
inherited Marfan's syndrome, the mutation
affects the FBN1 gene on chromosome 15.

[ Q: 1493 ] MRCPass - Basic Science

A 30 year old woman has recently
delivered a baby. She complains of groin
pains. On examination, she has weakness of
adduction and internal rotation of the hip.
There is sensory impairment over the medial
aspect of the thigh.

Which nerve is affected?

1- Femoral nerve

2- Sciatic nerve

3- Sacral nerve

4- Obturator nerve

5- Lateral cutaneous nerve of the thigh

Answer & Comments

Answer: 4- Obturator nerve

The obturator nerve supplies gracilis, the
adductor (longus, brevis, magnus) and the
skin over the medial aspect of the thigh.

[ Q: 1494 ] MRCPass - Basic Science

A study reveals an immediate rise in
blood pressure following infusion of a
hormone in a group of volunteers.

Which of the following hormones is likely to
have been used?

1- Angiotensin I

2- Angiotensin II

3- Growth hormone

4- Atrial natriuretic peptide

5- Brain natriuretic peptide

Answer & Comments

Answer: 2- Angiotensin II

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The final active messenger of the renin-
angiotensin pathway is angiotensin II.

Angiotensin II binds to ATI receptors to cause
vasoconstriction and fluid retention, both of
which lead to an increase in blood pressure.
Angiotensin II receptor blockers lower blood
pressure by blocking the ATI receptors.

[ Q: 1495 ] MRCPass - Basic Science

A 36 year old man has
gynaecomastia secondary to cirrhotic liver
disease.

What is likely to have caused the
gynaecomastia?

1- Reduced testosterone production

2- Increased testoterone metabolism

3- Increased oestrogen production

4- Reduced oestrogen metabolism

5- Increased LH levels

Answer & Comments

Answer: 4- Reduced oestrogen metabolism

Gynaecomastia in liver disease is due to an
imbalance in androgen and oestrogen levels,
the main contributor being reduced
oestrogen metabolism.

[ Q: 1496 ] MRCPass - Basic Science

A 30 year old male presents has
intermittent jaundice and anaemia. He is
diagnosed with glucose 6 phosphate
dehydrogenase (G6PD) deficiency. His wife
has normal G6PD activity.

What is the likelihood of their children
developing the condition phenotypically?

1- All their children will be affected

2- All their sons will be affected

3- All their daughters will be affected

4- 50% of their daughters will be affected

Answer & Comments

Answer: 5- None of their children will be
affected

Glucose 6 phosphate dehydrogenase (G6PD)
deficiency has X linked inheritance. The
affected patient has a chromosome XxY and
wife is XX. Therefore all daughers will be
carriers XxX and all sons normal XY. None of
these patients will have phenotypical G6PD
deficiency.

X chromosome w3h
mutation

Normal
ft male

l X f

UF «|

nn-al t

Alt daughters
art carriers

ffc

nil sum are

normal

[ Q: 1497 ] MRCPass - Basic Science

A 40 year old man has G6PD
deficiency.

Which one of the following substances is likely
to lead to red cell haemolysis?

1- Chloroquine

2- Paracetamol

5- None of their children will be affected

3- Trimethoprim

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4- Erythromycin

Answer & Comments

5- Baked beans

Answer: 3- Anticipation

Answer & Comments

Answer: 1- Chloroquine

Oxidative stress can be caused by drugs such
as chloroquine, quinine, primaquine and
sulphonamide (sulfomethoxazole),

nitrofurantoin, NSAIDs, dapsone and aspirin.
Fava beans can also cause haemolysis.

[ Q: 1498 ] MRCPass - Basic Science
Which one of the following cells

secretes intrinsic factor?

1- Pancreatic islet cells

2- Paneth cells

3- Gastric parietal cells

4- Hepatocytes

5- Myocytes

Answer & Comments

Answer: 3- Gastric parietal cells

Intrinsic factor is secreted by the gastric
parietal cells. It is a glycoprotein which binds
to vitamin Bi 2 best in an acid environment. It
then releases vitamin Bi 2 in the terminal
ileum where proteases digest the binding
proteins and vitamin B i2 is absorbed

[ Q: 1499 ] MRCPass - Basic Science

A 33 year old man has myotonic

dystrophy.

Which one of the following features is the
disease likely to exhibit?

Anticipation refers to increasing severity with
subsequent generations. It is common in
trinucleotide repeat disorders like
Huntington's disease, myotonic dystrophy
and fragile X syndrome, where triplet repeat
mutations in DNA are implicated.

The mechanism behind the expansion of the
triplet repeats is little understood. One
theory is that the increasing number of
repeats influence the overall shape of the
DNA, which can have an effect on its
interaction with DNA polymerase and thus
the expression of the gene.

[ Q: 1500 ] MRCPass - Basic Science

A 46 year old woman complains of
numbness in her left hand. On examination,
there was loss of sensation over the thumb
and first 2 fingers with paralysis of abductor
pollicis and opponens pollicis.

Which nerve is injured?

1- Median

2- Ulnar

3- Radial

4- Posterior interosseous

5- Anterior interosseous

Answer & Comments

Answer: 1- Median

The median nerve supplies the following
small muscles in the hands:

o Abductor pollicis brevis

1- Decreasing incidence with generations

o Opponens pollicis

2- Skips generations

3- Anticipation

4- Apoptosis

5- Mutation

o ± Flexor pollicis brevis
o 1st & 2nd lumbricals

The sensory supply is to palmar surface of
thumb, 2nd, 3rd & lateral 1/2 of 4th finger

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[ Q: 1501 ] MRCPass - Basic Science

Which of the following is a tumour
suppressor gene?

1- Ras

2- C-myc

3- N-myc

4- P53

5- Src

1- Wasp toxin levels

2- Serum complement C3 level

3- Serum complement C4 level

4- Serum total IgE level

5- Plasma tryptase activity

Answer & Comments

Answer: 4- Serum total IgE level

Answer & Comments

Answer: 4- P53

Mutated proto-oncogenes that cause cancer
are called oncogenes. All of the above are
oncogenes except for p53. Ras oncogene is
involved in sporadic tumours (colon and lung)
and rhabdomyosarcomas. c-myc

translocation occurs in Burkitt's lymphoma.
N-myc proto-oncogene is seen in
neuroblastoma. SRC oncogene is associated
with sarcoma. p53 is a tumour suppressor
gene.

Examples of Oncogenes

[ Q: 1502 ] MRCPass - Basic Science

A 18 year old man presents to
casualty complaining of difficulty breathing.
He had collapsed shortly after being stung on
the leg by a wasp. On examination, his
pressure was 80/40 mmHg, and there was
significant facial swelling.

Which one of the following investigations is
likely to confirm the nature of reaction?

This is a form of Type I hypersensitivity, also
known as immediate anaphylactic
hypersensitivity. It usually takes 15 to 30
minutes from the time of exposure to the
antigen. The reaction involves production of
IgE, in response certain antigens, which in
turn initiates a sequence of events.

[ Q: 1503 ] MRCPass - Basic Science

Which one of the following
conditions exhibit genomic imprinting?

1- Abetalipoproteinaemia

2- Patau's syndrome

3- Prader Willi syndrome

4- Down's syndrome

5- Motor Neuron disease

Answer & Comments

Answer: 3- Prader Willi syndrome

Genomic imprinting is exhibited by the
following conditions:

Prader Willi syndrome

Angelman syndrome

Beckw ith-Wiedemann syndrome

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Father

Mol her

imprittieti

\ j

T'hc ■mLirk".

■ The ’impnnlT

GAMbTbS

/fi

[Sperm

j i

I | hr J *1

1 w \l

The next
generation

Genomic imprinting - Disease severity
depends on w hether it is paternally or
maternally inherited.

[ Q: 1504 ] MRCPass - Basic Science

Which of these receptors helps os o
receptor to ollow HIV to enter octivoted T
cells ?

1- CD4

2- CD8

3- CXCR4

4- CCR4

5- CCR3

Answer & Comments

Answer: 3- CXCR4

CCR5 and CXCR4 are co-receptors which help
HIV binding (gpl20 to CD4 receptor) to
activated T cells.

034+ lymphocyte
or macrophage

CD4

molecules are known to play a central role,
but CXCR4 (fusin) and CCR5 are also involved,
possibly by removing gpl20 from the HIV
particle, thus exposing gp41, which is
necessary for the membrane attachment of

HIV.

[ Q: 1505 ] MRCPass - Basic Science

A 40 year old man with pleurisy for
five days was assessed. A moderately sized
pneumothorax was seen in a chest
radiograph.

His arterial blood gases on air showed pH
7.44, paC0 2 3.0 kPa, pa0 2 30.5 kPa, standard
bicarbonate 16 mmol/l.

How con the clinicol picture be explained?

1- Respiratory acidosis

2- Compensated metabolic alkalosis

3- Compensated metabolic acidosis

4- Compensated respiratory alkalosis

5- Compensated respiratory acidosis

Answer & Comments

Answer: 4- Compensated respiratory alkalosis

This patient had a normal pH but had both a
low PaC02 and a low standard bicarbonate.
The history indicates five days of

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hyperventilation, so this is likely to be a
compensated respiratory alkalosis.

[ Q: 1506 ] MRCPass - Basic Science

An 18 year old male with
meningococcal meningitis has further
investigations. It was found that he had low
properdin levels measured by the ELISA test.

How is this likely to have been inherited?

1- Autosomal dominant

2- Autosomal recessive

3- X linked recessive

CLASSICAL

LECTIN

ALTERNATIVE

PATHWAY

IMMUNE CARBOHYDRATES ACTIVATING

COMPLEXES COLLECTINS SURFFACES

Clq

Clr

Cls

C2 L

MBP

MASP

Clr

Cls

C3b

▼

C3b

C5b678(9)n (MAC)

Complement Pathways

4- X linked dominant

5- Mitochondrial inheritance

Answer & Comments

Answer: 3- X linked recessive

The pathw ays include the classic pathway
(Clqrs, C2, C4) and the alternative pathway
(C3, factor B, properdin). Properdin is a
protein encoded on the X chromosome.
Properdin stabilizes the C3 convertase
(C3bBb) of the alternative pathw ay, involved
in opsonisation. Meningococcal disease is a
prominent manifestation in a significant
fraction of reported cases in all clinical
patterns of complement deficiency,
particularly

[ Q: 1507 ] MRCPass - Basic Science

Northern blotting is a process which
involves detection of which of the following?

1- Immunoglobulins

2- Proteins

3- Viruses

4- RNA

5- DNA

Answer & Comments

Answer: 4- RNA

Northern blotting detects RNA, whilst
Southern blotting detects DNA.

those where opsonisation is defective.
Properdin deficiency states are X-linked
recessive, while other genetic defects within
the complement system appear to be
transmitted as autosomal recessive traits.

[ Q: 1508 ] MRCPass - Basic Science

A medical student reviews the
physiology of the oxygen dissociation curve.

Which one of the following is associated with
increased affinity of Hb for oxygen?

1- Chronic hypoxia

2- Anaemia

3- Increased 2,3 DPG

4- Cold temperature

5- Diabetic ketoacidosis

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Answer & Comments

Answer: 4- Cold temperature

Acidosis, raised 2,3 DPG, raised temperature,
hypoxia and anaemia all shift the 02-Hb
dissociation curve to the right, leading to
reduced affinity to 02.

[ Q: 1509 ] MRCPass - Basic Science

A patient with Crohn's disease and
an ileostomy has the following results:

Na 134 (135-145 mmol/l)

K 3.1 (3.5-5 mmol/I)

Cl 112 (92-107 mmol/l)

Bicarbonate 12 (20-30 mmol/l)

Urea 13 (3.2-8.1 mmol/l)

Creatinine 120 (70-110 mmol/l)

pH 7.25 (7.35-7.45 kPa)

paC0 2 3.1 (3.5-5 kPa)

The diagnosis is likely to be:

1- Normal anion gap metabolic acidosis

2- Metabolic alkalosis

3- Respiratory alkalosis

4- Respiratory acidosis

5- Hypochloraemic metabolic acidosis

Answer & Comments

Answer: 1- Normal anion gap metabolic
acidosis

Anion gap = (Na + K) - (CI+HC03), [normal
range 10-18 mmol/L]. In this case (134 + 3.2) -
(112 + 12) = 13.1.

Low bicarbonate in the presence of acidosis
suggests a metabolic cause, the probable
cause in this case is gastrointestinal
bicarbonate loss.

[ Q: 1510 ] MRCPass - Basic Science

A 40 year old patient has had EMGs
done to investigate a cause of peripheral leg
weakness.

Which of the following features suggests
axonal neuropathy?

1- Latency

2- Reduced conduction velocity

3- Reduced muscle action potential amplitude

4- Decreased frequency of conduction signals

5- Conduction block

Answer & Comments

Answer: 3- Reduced muscle action potential
amplitude

Reduced amplitude of action potential is seen
in axonal neuropathy. Reduced conduction
velocity or conduction block is seen in
demyelination.

[ Q: 1511 ] MRCPass - Basic Science

A i - 1 -

Which of the following are found in
both eukaryotic AND prokaryotic cells?

1- Linear DNA

2- Ribosomes

3- Chromosomes

4- Nuclear membrane

5- Introns

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Answer & Comments

Answer: 2- Ribosomes

Eukaryotes (higher organisms) have muliple
chromosomes in a genome which is
separated from the rest of the cell by a
nuclear membranes. Prokaryotes lack a
membrane bound nucleus, their DNA occurs
in a circular form. Transcription of eukaryotic
genes requires noncoding sequences (introns)
in the mRNA which is spliced out before
translation at the ribosome. Both eukaryotes
and prokaryotes have ribosomes.

[ Q: 1512 ] MRCPass - Basic Science

i ^ ) Which of the following is
characteristically inherited in an autosomal
recessive manner?

1- Adult polycystic kidney disease

2- Cl esterase inhibitor deficiency

3- Sickle cell disease

4- Achondroplasia

5- Familial hypercholesterolaemia

Answer & Comments

Answer: 3- Sickle cell disease

Sickle cell disease is inherited in an autosomal
recessive manner (sickle cell trait is inherited
in an autosomal dominant manner).

Achondroplasia, adult polycystic kidney
disease, Cl esterase inhibitor deficiency
(hereditary angiooedema) and familial
hypercholesterolaemia are usually inherited
in an autosomal dominant manner.

[ Q: 1513 ] MRCPass - Basic Science

Which one of the following
statements describes genomic imprinting?

1- Expansion of repeats with time

2- Genotypic variability from maternal and
paternal chromosomes

3- Phenotypic presentation depends on either
maternal or paternal chromosome

4- Imprinting of mutations on genomes

5- Mendelian inheritance

Answer & Comments

Answer: 3- Phenotypic presentation depends
on either maternal or paternal chromosome

Genomic imprinting refers to the difference in
phenotypic presentation depending on the
origin of the disease chromosome from either
maternal or paternal.

Father Mother

Genomic imprinting - The imprinting "mark" is
represented by a stippled box, and the
imprinted state is indicated with an X.

[ Q: 1514 ] MRCPass - Basic Science

Phosphorylation of protein tyrosine
residues is associated with which of the
following?

1- Protein synthesis

2- DNA replication

3- Proteosomal degradation

4- Cell signaling pathways

5- Protein degradation

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Answer & Comments

Answer: 4- Cell signaling pathways

Protein tyrosine kinases (PTKs) are enzymes
which catalyze the phosphorylation of
tyrosine residues. These enzymes are
involved in cellular signalling pathw ays and
regulate key cell functions such as
proliferation, differentiation, anti-apoptotic
signalling and neurite outgrow th.
Unregulated activation of these enzymes,
through mechanisms such as point mutations
or over-expression, can lead to various forms
of cancer as well as benign proliferative
conditions. Indeed, more than 70% of the
known oncogenes and proto-oncogenes
involved in cancer code for PTKs.

Activated tyrosine-kinase
receptor (phosphoryiated
dimer)

Tyrosine Kinase Receptor

Cellular

response

Cellular

response

Signal molecules

Activated

proteins

[ Q: 1515 ] MRCPass - Basic Science

A man with mild bleeding disorder is
being considered for aspirin for acute
coronary syndrome.

Which one of the effects of aspirin is
beneficial in coronary artery disease?

1- Reduction in thromboxane A2 synthesis

2- Increase in the prostaglandins

3- Glycoprotein MB MIA receptor inhibition

4- ADP receptor antagonism

5- Increase in COX enzymes

Answer & Comments

Answer: 1- Reduction in thromboxane A2
synthesis

Aspirin blocks the synthesis of COX1 and
COX2 enzymes.

This leads to a reduction in the prostaglandin
PGG2, PGH2 —» thromboxane TXA2 synthesis
i . This leads to i platelet aggregation.

Phospholipids

Phospho- ->

Ilpm

Cyelo-

Soiicyfpfts

Iftiiprofott

Thromboxane

Vasoconstrictor

Prothrombin

pgi 2

PGEn

Vasodilation

Antithrombotic

Aspirin action (salicylates)

[ Q: 1516 ] MRCPass - Basic Science

A 12 year old child is investigated
for multiple skin abscesses. Swabs grow
staphylococcus aureus. His cousin had died
from a serious septic illness a few years ago.

What form of immune deficiency is the child
likely to have?

1- Eosinophil

2- Neutrophil

3- Complement

4- Lymphocyte

5- Immunoglobulin A

Answer & Comments

Answer: 2- Neutrophil

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Primary neutrophil deficiencies are rare and
are due to an abnormality, usually inherited,
of the neutrophil itself. The problem can
affect phagocytosis (e.g. deficiency of an
adhesion molecule, CD18/LFA deficiency, on
the neutrophil surface). Patients with
neutrophil defects suffer from recurrent chest
infections with bacteria or fungi, recurrent
skin abscesses often caused by
Staphylococcus aureus and poor wound
healing.

[ Q: 1517 ] MRCPass - Basic Science

A 40 year old man attends a fertility
clinic. Examination shows that he is tall, thin
and has bilateral gynaecomastia.

Investigation show high levels of urinary
gonadotrophins.

What is the likely diagnosis?

1- Homocystinuria

2- Marfan syndrome

3- Testicular feminisation syndrome

4- Noonan's syndrome

5- Klinefelter's syndrome

Answer & Comments

Answer: 5- Klinefelter's syndrome

Klinefelter's syndrome is the most common
chromosomal disorder associated with male
hypogonadism and infertility. It is defined
classically by a 47, XXY karyotype with
variants demonstrating additional X and Y
chromosomes.

The syndrome is characterized by
hypogonadism (small testes,

azoospermia/oligospermia), gynecomastia at
late puberty, psychosocial problems,
hyalinization and fibrosis of the seminiferous
tubules, and elevated urinary gonadotropins.

[ Q: 1518 ] MRCPass - Basic Science

Which one of the following amino
thyroxine derived from?

1- Leucine

2- Glycine

3- Cystathione

4- Tryptophan

5- Tyrosine

acids is

Answer & Comments

Answer: 5- Tyrosine

Each molecule of thyroxine is derived from
Two tyrosine molecules and three (T3) or four
(T4) iodine molecules.

[ Q: 1519 ] MRCPass - Basic Science

A 30 year man has acute onset of
pain around his left eye. On examination, he
has a left ptosis and a small left pupil but both
react normally to light. Visual acuity, fields
and eye movements are normal.

The site of injury is to which of the following?

1- Midbrain

2- Superior cervical ganglion

3- Stellate ganglion

4- Pons

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5- Geniculate ganglion

Answer & Comments

Answer: 2- Superior cervical ganglion

The diagnosis is Horner's syndrome. The
sympathetic nerve fibres from the
hypothalamus travel through brainstem and
cervical cord to T1/T2. These synapse on
preganglionic sympathetic fibres, travel up
sympathetic chain to superior cervical
ganglion, and then synapse onto
postganglionic fibres which travel with
common and internal carotid arteries.

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CAVrUNOUB

riR»T //f
ecRvicAtO' /

sruvt

CAROTID nUUK

uracil ccftviCAi
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NCftVC

M'OOIC CCRVICAL

CAROltOR

MIDDLE CARDIAC
NCMVC

AUlVAMT *I»R

f i m T

ItCRVC

IIUNTM

CERVICAL
Nf AVC

[ Q: 1520 ] MRCPass - Basic Science

Two strains of Staph aureus are
isolated and both are resistant to ampicillin.
Strain 1 retains its resistance to amplicillin
when grown from multiple generations in the
absence of ampicillin. How ever strain 2 loses
its resistance when grow n in the absence of
ampicillin.

Which of the following best explains the loss
of antibiotic resistance in strain 2?

1- Ampicillin has eliminated resistant bacteria

2- Variability with generations

3- Transposition of another sequence into the
resistance gene

4- Changes in bacterial DNA ligase

5- Loss of a plasmid containing the resistance
gene

Answer & Comments

Answer: 5- Loss of a plasmid containing the
resistance gene

Bacteria develop resistance to antibiotics by
gaining genes which encode particular
proteins which offer protection organism.
Sometimes this occurs by mutation but at
other times gene may be acquired from
another bacterial species. The genes are
contained in plasmids (circular segments of
DNA) separate from bacterial chromosome.
Plasmids can easily spread from one bacteria
or equally lost. Transfer, loss and gain of
plasmids are relatively common compared to
single mutations.

[ Q: 1521 ] MRCPass - Basic Science
A patient has the following blood

results.

sodium 131 mmol/l

potassium 4.5 mmol/l

urea 5 mmol/l

creatinine 100 pmol/l

glucose 12 mmol/l

What is her plasma osmolality?

1- 262

2- 267

3- 279

4- 280

5- 290

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Answer & Comments

Answer: 3- 279

Plasma osmolality is estimated by the
following formula 2x Na + Urea + glucose. 262
+ 5 + 12 = 279 (mmol/kg). An example: high
serum osmolality could be caused by HONK.

[ Q: 1522 ] MRCPass - Basic Science

The level of cellular telomerase
activity will affect which of the following?

1- Cell death

2- The number of potential cell divisions

3- RNA synthesis

4- The rate of cell growth

5- Cell survival

Answer & Comments

Answer: 2- The number of potential cell
divisions

The telomere is a DNA sequence at end of
each chromosome which becomes
progressively shorter with each division the
cell undergoes. The enzyme telomerase is
able the lengthen telomere thus preventing
the limitation tow ards cell division.

Telomerase
RNA ^

Telomerase Activity

2- Stellate ganglion

3- Trochlear ganglion

4- Vestibular nucleus

5- Ciliary ganglion

Answer & Comments

Answer: 5- Ciliary ganglion

The pathway of the pupillary light reflex
consists of: retinal receptor cells, bipolar cells,
ganglion cells, optic nerve and tract, lateral
geniculate bodies, superior colliculus and
pretectal nucleus of the high midbrain,
Edinger-Westphal nucleus, efferent Two
neurone pathway via the oculomotor nerve
(lllrd nerve), ciliary ganglion, constrictor
muscle of the iris.

[ Q: 1524 ] MRCPass - Basic Science

Which one of the following is the
best indicator of osteoblastic activity?

1- Aspartate aminotransferase

2- Calcium

3- Albumin

4- Alkaline phosphatase

5- Leucocytes

Answer & Comments

Answer: 4- Alkaline phosphatase

Bone alkaline phosphatase (B-ALP) is
produced by the osteoblast It is an index of
early osteoblast differentiation and activity.

the pupillary reflex?

1- Occipital cortex

[ Q: 1523 ] MRCPass - Basic Science
Which of these areas is involved in

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^ [ Q: 1525 ] MRCPass - Basic Science

t ----

0 Which one of the following organs is

in direct contact anterior surface of left

kidney , without being separated from it by

peritoneum?

1- Spleen

2- Descending colon

3- Stomach

4- Pancreas

5- Liver

4- All the sons are affected

5- Half of the sons are affected

Answer & Comments

Answer: 4- All the sons are affected

G6PD deficiency is X linked recessive.
Assuming the husband is not a gene carrier -
her genotype is XXXX and her husband is XY.
Both daughters will have the genotype XXX
and will be carriers. Both sons will have the
genotype XXY and are affected.

Answer & Comments

Answer: 4- Pancreas

Primarily retroperitoneal organs are those
that develop and remain behind (outside) the
peritoneum (kidneys, aorta, pancreas).

Secondarily retroperitoneal organs are those
that develop within the peritoneal sac but are
pushed behind it during growth (e.g.
ascending colon, most of duodenum).

Normal structures of the Retroperitoneum

[ Q: 1526 ] MRCPass - Basic Science

A 45 year old woman has G6PD
deficiency.

Which one of the following is true regarding
the children?

1- Half the daughters will be affected

2- All the daughters will be affected

3- Half the daughters will be carriers

[ Q: 1527 ] MRCPass - Basic Science

A 53 year old lady with previous
peptic ulcer disease was admitted with
persistent vomiting. She looked dehydrated.

Her blood results were sodium 140 mmol/l,
potassium 2.5 mmol/l, chloride 86 mmol/l, pH
7.5, paC0 2 6.0 kPa, pa0 2 14 kPa, standard
bicarbonate 40 mmol/l.

What is the acid-base disturbance?

1- Hyperchloraemic metabolic alkalosis

2- Hypochloraemic metabolic alkalosis

3- Respiratory acidosis due to type II

respiratory failure

4- Respiratory acidosis due to type I

respiratory failure

5- High anion gap metabolic acidosis

Answer & Comments

Answer: 2- Hypochloraemic metabolic

alkalosis

This patient had alkalosis due to a high
standard bicarbonatemetabolic alkalosis. The
PaC02 was appropriately low in
compensation. This was a hypokalaemic
hypochloraemic state because of potassium
and chloride loss from vomiting. Treatment
was of the underlying cause (pyloric stenosis)
and intravenous sodium chloride with
potassium.

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^ [ Q: 1528 ] MRCPass - Basic Science

f --—-- -

Glycolysis converts glucose into
which of the following?

1- Glycerol

2- Acetyl co A

3- Fructose

4- Pyruvate

5- Citrate

5- Klinefelter's syndrome

Answer & Comments

Answer: 3- Fragile X syndrome

Chromosomal analysis is useful for Turner's
(XO), Down's (trisomy 21) and Klinefelter's
(XXY). In Fragile X DNA analysis is useful to
determine trinucleotide repeats (CGG
repeats)

Answer & Comments

Answer: 4- Pyruvate

Glucose, a six-carbon sugar, is converted to
Two molecules of a three-carbon unit,
pyruvate in glycolysis.

G lycolysis/ G luconeogenesis Overview

ATP Glucose

ADP

Fructose _ ADP ATP G-6-P

(Muscle, kidney,
adipose—UK)

1 UDPGal UDPG ATP ADP
Gal-l-P

Galactose

Pi + NAD+:

NADH + H+"

adp:

atp:

ATP-^ F ' 6 - p

► p i

ADP’*' y | NADH NAD+

F-l fa- top 4 4 Glycerol-3-P

A V

* DHAP ■*- F-lFructose

(major route in liver-GK)

Glycerol
ATP ADP

GA-3-P •+ -► ^- y

ADP^ ^

I G1 ^ ceK

Glyceraldehyde

1 toPGA

ATP

3-PGA

GDP +Pi GTP

NAD+ NADH+H+

CO 2 +NADH +H + :

* Heavy arrows indicate
biologicall y i rreversi ble
reactions

*Number of arrows
indicates relative
flux of reactions.

Oxaloacetate

Lactate ~z v v ZTPyruvate
CoASH + NAD+ — -I.

Acetyl CoA

[ Q: 1529 ] MRCPass - Basic Science

In which of the following conditions
would DNA analysis be useful?

1- Turner's syndrome

2- Down's syndrome

3- Fragile X syndrome

4- Creutzfeld Jakob syndrome

[ Q: 1530 ] MRCPass - Basic Science

Which of the following describe a

codon correctly?

1- A 3-base pair unit of DNA that codes for an
amino acid

2- A 3-base pair unit of RNA that codes for an
amino acid

3- A 2-base pair unit of DNA that codes for a 4
base pair unit of RNA

4- A 5-base pair unit of RNA that codes for an
amino acid

5- A 1-base pair unit of DNA that codes for an
amino acid

Answer & Comments

Answer: 2- A 3-base pair unit of RNA that
codes for an amino acid

During translation of mRNA, the bases are
'read' in a 3 base pair or triplet code, each 3-
base pair unit being referred to as a codon.

Amino Acid

tRNA

n n m m

Hlo.

Anticodon

Codon

mRNA

[ Q: 1531 ] MRCPass - Basic Science
An 18 year old woman has an

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inherited vitamin D metabolic disorder. She
has Two brothers who are unaffected.

She has three sisters who are all affected. Her
father is affected but not her mother.

What is the mode of inheritance?

1- Autosomal Dominant

2- Autosomal Recessive

3- Mitochondrial inheritance

4- X linked Recessive

5- X linked Dominant

Answer & Comments

Answer: 5- X linked Dominant

X linked dominant disorders are rare (e.g.
Vitamin D resistant rickets). The condition
affects both sexes but females more than
males. All children of a homozygous mother
are affected (XxXx). Half of the sons and half
of the daughters inherit the disorder from an
affected mother with the trait (XxX). An
affected father (XxY) passes the disease to all
his daughters (XxX) but none of his sons (XY).

A systemic anaphylactoid reaction can occur
with iv N acetylcysteine.

Features of this are bronchospasm,
hypotension, tachycardia, flushing,
angioedema and rash.

[ Q: 1533 ] MRCPass - Basic Science

A patient has multiple skin lesions
that consist of sessile and pedunculated
papules and nodules over the entire surface
of his body. In addition, there are multiple
pigmented macules on his trunk and axillary
freckling. There are Lisch nodules on the iris.

The inheritance of this condition is:

1- Polygenic inheritance

2- Autosomal recessive

3- Autosomal dominant

4- X-linked dominant

5- X-linked recessive

Answer & Comments

Answer: 3- Autosomal dominant

[ Q: 1532 ] MRCPass - Basic Science

An 18 year old girl took an overdose
of 20 g of paracetamol with 3 pints of beer.
Upon presentation to hospital 6 hours later,
she was commenced on intravenous N -
acetylcystine immediately. 1 hour later she
developed tachycardia, flushing and w
heezing.

What is likely to have caused this?

1- IgE hypersensitivity reaction

2- Disulfiram type reaction

3- Interaction with alcohol

4- Interaction with paracetamol

5- Late effects of paracetamol overdose

Answer & Comments

Answer: 1- IgE hypersensitivity reaction

The diagnosis is neurofibromatosis, which has
autosomal dominant inheritance.

Skin neurofibromas

[ Q: 1534 ] MRCPass - Basic Science

• A 55 year old woman has visual
problems. On examination, she has
a right sided third nerve palsy.

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Which one of the following occurs typically in
a third nerve palsy?

1- Small pupil

2- Reactive pupil

3- Exopthalmos

4- Ptosis

3- Autosomal dominant

4- X linked recessive

5- Multifactorial

Answer & Comments

Answer: 2- Autosomal recessive

5- Eye looks upward

Answer & Comments

Answer: 4- Ptosis

3rd nerve palsy leads to ptosis, dilated
unreactive pupil and eye looking down and
out (due to unopposed superior oblique and
abducent nerves. Exopthalmos can be
associated (e.g. graves disease) but is not a
feature of 3rd nerve palsy.

Third Nerve Palsy on the Right

[ Q: 1535 ] MRCPass - Basic Science

An 23 year old male has a chronic
cough and recurrent bronchopulmonary
infections. On examination he is clubbed and
there are coarse late inspiratory crepitations
(crackles) at both lung bases. His sweat
sodium concentration is 80 mmol/L (normal
60 mmol/L).

The mode of inheritance of the condition is:

1- X linked dominant

2- Autosomal recessive

Cystic fibrosis is caused by a gene mutation
(CFTR gene) on the long arm of chromosome
7. It is autosomal recessive.

[ Q: 1536 ] MRCPass - Basic Science

A 35 year old man had an injury
whilst doing DIY work. He has numbness
around the half of his fourth finger and last
digit.

Which of these motor functions is likely to be
impaired?

1- Flexion of the fourth finger

2- Extension of the fourth finger

3- Extension of the little finger

4- Thumb abduction

5- Thumb adduction

Answer & Comments

Answer: 5- Thumb adduction

The distribution of sensory loss implies an
ulnar nerve lesion. Flexion of the fingers and
thumb abduction is supplied by the median
nerve. Extension of the fingers are supplied
by radial nerve.

[ Q: 1537 ] MRCPass - Basic Science

A 25 year old male presents with
wasting and weakness of the muscles of the
pelvic girdle. There is evidence of generalised
muscular hypertrophy. His maternal
grandfather had a similar disorder.

The mode of inheritance is:

1- Mitochondrial inheritance

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2- X linked dominant

3- Autosomal dominant

4- Autosomal recessive

5- X-linked recessive

Answer & Comments

Answer: 5- X-linked recessive

The diagnosis is Becker's muscular dystrophy.
This is X linked recessive.

[ Q: 1538 ] MRCPass - Basic Science

Which one of the following describes
formation of proteins along the mRNA in a 5'
to 3' direction ?

1- Reverse transcription

2- Transcription

3- Translation

4- Duplication

5- Splicing

Answer & Comments

Answer: 3- Translation

Translation alw ays begins with a methionine
residue. The mRNA is translated in the 5' to 3'
direction and is read in groups of 3 bases,
which are known as codons. New amino acids
are added to the carboxyl terminus of the
grow ing peptide chain.

Gly Leu

Tyr

Growing polypeptide chi

Set

sin

lieu)

Asn

i Gly )

C G T C A A

I 'll”

CUCUUGG6UCC6CAGUUAAUUUCUAUC

I 1 I I I ' l \ I i I I I I I I I I I I I M I i I I

mRNA

Ribosome

Translation and Protein synthesis

[ Q: 1539 ] MRCPass - Basic Science

A 35 year old woman presents with
a right sided Horner's syndrome
with anhydrosis of the medial side of the right
forehead.

The cause of the Horner’s is most likely due to:

1- Cervical rib

2- Lateral medulla infarct

3- Injury around internal carotid artery

4- Compression from pancoast tumour

5- Hypothalamus insult

Answer & Comments

Answer: 3- Injury around internal carotid
artery

All are potential causes of Horner's syndrome.
How ever, the sympathetic plexus around the
internal carotid artery supplies the medial
side of the forehead, hence anhydrosis to
that region specifically points tow ards injury
to the internal carotid artery at that site.

Right sided Horner's (ptosis, miosis,

anhydrosis)

[ Q: 1540 ] MRCPass - Basic Science

Which of the following is the product
of the beta-oxidation of fatty acids?

1- Glucose 6 phosphate

2- Pyruvate

3- Oxaloacetate

4- Hydroxymethylglutaryl Coenzyme A

5- Acetyl Coenzyme A

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Answer & Comments

Answer: 5- Acetyl Coenzyme A

Beta oxidation is the process by which fatty
acids are broken down to smaller units such
that substances such as Acetyl Coenzyme A
can enter the citric acid cycle.

p a

H s Hj Hi 9
?—r— r — r —L

Acetyl Co-A is a two-carbon unit which is
formed from pyruvate. Pyruvate is the end
product of glycolysis. This reaction is
catalysed by pyruvate dehydrogenase. Acetyl
coA is the substrate for the citric acid cycle.
With each turn of the cycle, Two carbon
atoms enter as acetyl-CoA and Two carbon
atoms are lost as C02.

16 C R—C C—C —“—SC Oft pal mitoyl-CoA

FAO

acyl-CoA I

hydrriasa I T* FADI-lj

1 P

H 0

CoA pyruvate

NAD' 'N. I pyruvate

)\ dehydrogenase

NADH-* - ' \

CO,

acetyl-CoA

-sa-

■SCoA iran*-A-anoyl-CoA

enoyl-CoA

hydrolase

1 /

H 2 0

H,0

citrate

aconitase c/s-aconitate H,0

repeat mee

14 O'HH 0

R-C—ll—SCoA l>

A |!|

p'hjdroK y-aeyl ■ CoA

NADH

NAD'

malate
dehydrogenase

isocitrate

NAD'

pkhydroxyacyl-CoA 1

1 - NAD

malate

isocitrate A

dehydrogenase j

NADH+ H'

dehydrogenase |

A fumarase

M o

iP"k^^SCyl- CoA

a-ketoglutarate

fumarate

^ acyl-CcAacetyltransferase II CoASH

14 c R-C—i-SCoA 4 - HjC-i—SCoA^

fio^-CoA ae^CoA

myri stoyl-CoA

a-ketoglutarate

dehydrogenase

succinyl-CoA

NADH

CO,

repeal 6 more times

I 1

7 HjC—U-SC(rt2C
age*yl-CoA

Fatty Acid Oxidation

[ Q: 1541 ] MRCPass - Basic Science

Which of the following is the end
product of glycolysis which feeds into the
citric acid cycle?

1- Glucose

2- Fructose

3- Citrate

4- Pyruvate

5- Acetyl coA

Answer & Comments

Answer: 4- Pyruvate

[ Q: 1542 ] MRCPass - Basic Science

A 60 year old man with type 1
diabetes and diabetic nephropathy was
recovering on a surgical ward after a total
colectomy and ileostomy. He had persistent
metabolic acidosis and the surgeons
concerned about his high potassium
concentration and that there may have been
some ischaemia in the abdomen causing the
acidosis.

However, the patient appeared well perfused
and had normal vital signs. He had normal
fluid balance and his results showed:

sodium 130 mmol/l

potassium 8.5 mmol/l

creatinine 200 pmol/l (2.16 mg/dl)

chloride 109 ?mol/l

8 am cortisol 500 nmol/I (18 pg/dl)

pH 7.29

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paC0 2 3.5 kPa
pa0 2 14 kPa

standard bicarbonate 12 mmol/l
Whot is the metabolic disturbance?

1- Hyporeninaemic hyperaldosteronism

2- Hyporeninaemic hypoaldosteronism

3- Hyperreninaemic hyperaldosteronism

4- Hypokalaemic hyperaldosteronism

5- Hypochloraemic hypoaldosteronism

Anticipation refers to the increased severity
of disease at earlier age of onset with
successive generations.

It is a feature of trinucleotide repeat
disorders, which are:

■ spinocerebellar ataxia

■ fragile X

■ myotonic dystrophy
Huntington's disease

Answer & Comments

Answer: 2- Hyporeninaemic

hypoaldosteronism

This man had diabetic nephropathy which
predisposes to renal tubular acidosis. Type 4
(hyporeninaemic hypoaldosteronism) RTA is
typically associated with high potassium and
is found in diabetic and hypertensive renal
disease. This patient also had acidosis due to
low bicarbonate. The PaC02 was
appropriately low in compensation. The anion
gap was normal (13.5 mmol/l). This makes
intra-abdominal ischaemia (which causes
lactic acidosis) unlikely.

[ Q: 1543 ] MRCPass - Basic Science

Genetic anticipation occurs
characteristically in which one of the
following conditions?

1- Wilson's disease

2- Spinocerebellar ataxia type 1

3- Haemochromatosis

4- Neurofibromatosis

[ Q: 1544 ] MRCPass - Basic Science

A 20 year old man with a tall stature
has a cardiac murmur characterized by a
midsystolic click. An echocardiogram reveals
mitral valve insufficiency with upw ard
displacement of one leaflet. There is also
aortic root dilatation of 4 cm.

A mutation involving which of the following
genes is likely to be present in this patient?

1- Fibrillin

2- Ankyrin

3- Spectrin

4- VEGF

5- CFTR

Answer & Comments

Answer: 1- Fibrillin

Marfan's syndrome is described. This is a
connective tissue disorder with the fibrillin
gene abnormality, leading to associated
floppy mitral valve and also cystic medial
necrosis which predisposes aortic dissection.

5- Tuberous Sclerosis

Answer & Comments

Answer: 2- Spinocerebellar ataxia type 1

^ [ Q: 1545 ] MRCPass - Basic Science

f§ --'-

# A 45 year old woman presents with
weakness of her left upper limb, which
developed overnight. She says she usually
sleeps on an armchair.

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On examination there is weakness of
extension of her left elbow , a wrist drop and
absent sensation over the first interosseus
space of her left hand on the dorsal aspect.

Where is the lesion?

1- Brachial nerve

Answer & Comments

Answer: 3- 50%

Hereditary spherocytosis is inherited in an
autosomal dominant manner and hence the
chance of the child being affected is 50%.

2- Radial nerve

3- Ulnar nerve

4- Musculocutaneous nerve

5- C5 C6 root at the brachial plexus

Answer & Comments

Answer: 2- Radial nerve

The weakness of extension of the elbow
indicates weakness of the triceps, hence the
lesion should be in the radial nerve, probably
higher up at the axilla. Lesions of the radial
nerve in the spiral groove spare the triceps.

Wrist Drop in Radial Nerve injury

[ Q: 1546 ] MRCPass - Basic Science

A 27 year old man has hereditary
spherocytosis (heterozygous) is married to an
unaffected female. They seek advice
regarding inheritance of the condition.

What is the chance of their child being
affected?

1 - 0 %

[ Q: 1547 ] MRCPass - Basic Science

A 49 year old man was admitted
with chest pain. The ECG showed an anterior
wall myocardial infarction. He initially settled,
but after 48 hours, he complained of further
chest pain with ECG changes.

Which enzyme is the earliest to rise in
myocardial infarction?

1- LDH

2- CK-MB

3- Myoglobin

4- Troponin T

5- AST

Answer & Comments

Answer: 3- Myoglobin

Myoglobin rises rapidly in myocardial
infarction. A doubling of the enzyme within 2
hours is very suggestive of an Ml. Troponin
and CKMB start to rise after 3 hours, and LDH
after 12 hours.

A 20 year old man has metabolic
acidosis with a pH of 7.2.

He has the following results: sodium 135
mmol/I, potassium 4.8 mmol/I, urea 8 pmol/l,
creatinine 110 pmol/l, chloride 105 (95-107)
mmol/l, bicarbonate 18 (20-28) mmol/l.

[ Q: 1548 ] MRCPass - Basic Science

2- 25%

3- 50%

4- 75%

5- 100%

What is his anion gap?
1- 16

2- 16.8

3- 17.2

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4- 18.6

5- 20

Answer & Comments

Answer: 2-16.8

Anion gap is calculated by the formula (Na +
K) - (Cl + [HC03-]). 135 + 4.8 - 105 - 18 = 16.8.
Normal anion gap is 8-16.

1- C1

2- C2

3- C3

4- C4

5- C5

Answer & Comments

Answer: 5- C5

[ Q: 1549 ] MRCPass - Basic Science

A differential diagnosis list is being
considered for a child who is short.

Which of the following abnormalities is
associated with short stature?

1- 47, XXY karyotype

2- 47, XYY karyotype

3- 45, XXXY karyotype

4- 45, XO karyotype

5- Fragile X syndrome

Answer & Comments

Answer: 4- 45, XO karyotype

Turner's syndrome (45, XO karyotype) is
associated with short stature.

C5-9 complements are part of the membrane
attack complex which are important in
protection against organisms such as
meningococci.

[ Q: 1551 ] MRCPass - Basic Science
Which of the following is an end

product of porphyrins?

1- Bilirubin

2- Globulin

3- Haem

4- Glycine

5- Lactate

Answer & Comments

Answer: 3- Haem

X ) (

y 4

i #

S l

it ii n 5

N V 10

# ii

* M

II 12

«<

'J 11 tl k5

15 Ift 17 IX

* •

* * 4 % f

51 55 \

m 1 1 A

45, XO karyotype

The first step in the biosynthesis of haem is
the condensation of glycine with succinyl CoA
to form delta-aminolevulinic acid. This
reaction occurs in the mitochondria and is
negatively regulated by haem. The reaction
pathway then proceeds through intermediate
products porphobilinogen, uroporphyrinogen
III, coproporphyrinogen III, protoporphyrin IX,
and finally haem.

[ Q: 1550 ] MRCPass - Basic Science

Which one of the following
complement deficiencies predisposes to
susceptibility to meningococcal infections?

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Glycine

H +

C0 2 + CoA

Succinyl-CoA -4- — Pyruvate metabolism

_' -

Am i n o I evu I i n ate synth a s e

H 2 0 + H +

6-Aminolevulinate

Aminolevulinate dehydratase

Porphobilinogen

H 2 0

NH,

I _

Porphobilinoqen deaminase

Hydroxymethylbilane

Uro porphyrinogen-1

h 2 0

synthase

Uroporphyrinogen III

Uroporphyrinogen decarboxylase

CO,

Coproporphyrinogen III

o 2 -^\

C o p ro p o rphyri n o q en oxi d a s e

—1

CO.

Protoporphyrinogen IX

H 2 0

Protoporphyrinogen oxidase

Protoporphyrin IX

Fe 2+

. i

Ferrochelatase

Protoheme (Heme) < -Hemoglobin digestion

Quervain's tenosynovitis which is
inflammation of the abductor pollicis longus
and extensor pollicis brevis.

Finkelstein's test

[ Q: 1553 ] MRCPass - Basic Science

A 20 year old man has jaundice, but
he has normal liver function tests apart from
a raised bilirubin.

Porphyrin metabolism

[ Q: 1552 ] MRCPass - Basic Science

A 40 year old female complains of
tenderness in the radial aspect of his wrist.
She is a professional golf player.

With the thumb flexed across the palm of the
hand, movement of the wrist into flexion and
ulnar deviation causes pain.

What is the diagnosis?

1- De Quervain's tenosynovitis

2- Tennis elbow

3- Golfer's wrist

4- Ulner nerve lesion

5- Radial nerve lesion

Answer & Comments

Answer: 1- De Quervain's tenosynovitis

The movements described above is the
Finkelstein's test. This is diagnostic of De

Which one of the following enzymes catalyses
the conjugation of bilirubin?

1- Amylase

2- Glucose 6 phosphatase

3- Glucuronyl transferase

4- Xanthine oxidase

5- Phenylalanine hydroxylase

Answer & Comments

Answer: 3- Glucuronyl transferase

Bilirubin is conjugated with glucuronic acid by
the enzyme bilirubin uridine 5-diphosphate
glucuronyl transferase (UGT).

Crigler-Najjar (CN) syndrome is a congenital
familial nonhemolytic jaundice associated
with high levels of unconjugated bilirubin due
to UGT1 mutation.

Dubin-Johnson syndrome is asymptomatic
mild jaundice due to impaired excretion of
bilirubin. In contrast to Gilbert's syndrome,

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the hyperbilirubinemia is conjugated and bile
appears in the urine.

Ery throcy tes

o 0

_ ± _

r Macrophages of the "'i

^Spleen S'-. Bone Marrow J

heme

bilirubin

Bilirubin (conjugated)

Conjugation of Bilirubin catalysed by
Glucuronyl Transferase

[ Q: 1554 ] MRCPass - Basic Science

A 40 year old man has an anterior
mediastinal mass seen on CT scan.

Which of the following is unlikely to be o
co use for the mass?

1- Thyroid

2- Thymus

3- Thoracic sarcoma

4- Teratoma

5- Tumour

thorax showing a large mediastinal mass

^ [ Q: 1555 ] MRCPass - Basic Science

f — - J ~ * 1 2 3 4 5 - - - -

Which one of these vitamin D
products is formed in the liver?

1- 1-hydroxycholecalciferol

2- 24-hydroxycholecalciferol

3- 25-hydroxycholecalciferol

4- 24,25-dihydroxycholecalciferol

5- 1,25-dihydroxycholecalciferol

Answer & Comments

Answer: 3- 25-hydroxycholecalciferol

The active form of vitamin D - 1,25-
dihydroxycholecalciferol is formed by
regulated hydroxylations. The 25-alpha
hydroxylation is performed in the liver, and
the 1-alpha hydroxylation in the kidney.

Answer & Comments

Answer: 3- Thoracic sarcoma

The four Ts for mediastinal masses (anterior)
are thyroid, thymoma, teratoma and tumour
(lymphomas).

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SKIN PRODUCTION

DIET

^LIVER)

JLch ?

25 (OH)-Vitamin D

>CH

HO OH

1,25 ( 0 H) 2 Vitamin D

[ Q: 1556 ] MRCPass - Basic Science

In genetics , what is the meaning of
genetic mosaicism?

1- An activated X chromosome

2- RNA is transcribed into DNA

3- An individual has 2 or more genetic cell
lines

4- There is always the same number of
chromosomes in all cells

5- A form of chromosome trisomy

Answer & Comments

Answer: 3- An individual has 2 or more
genetic cell lines

A Barr body is an inactivated X chromosome.
Mosaicism is as defined above - it can
comprise of cells of 46 or 47 chromosomes in
the same zygote.

(HI DIVISION

O O

0 9 0 0

66® @0606

o NOtMAl cats «U5 WI1H MUUnON

Genetic Mosaicism

[ Q: 1557 ] MRCPass - Basic Science

An 20 year old woman with alpha 1
antitrypsin deficiency attends a genetics clinic
for advice reagarding the likelihood of her
potential child would be affected.

What is mode of inheritance of this disease?

1- Autosomal dominant

2- Autosomal recessive

3- X linked dominant

4- X linked recessive

5- Polygenic

Answer & Comments

Answer: 2- Autosomal recessive

The inheritance of alpha 1 antitrypsin (A1AT)
deficiency is autosomal recessive. The alleles,
how ever, are codominant, which means each
allele is responsible for 50% of the circulating
A1AT level. The production of alphal
antiprotease is controlled by a pair of genes
at the protease inhibitor (Pi) locus. The most
common (90%) allele is M (PiM), and
homozygous individuals (MM) produce
normal amounts of alphal antiprotease
(serum levels of 20-53 mmol/L). Deficient
levels of alphal antiprotease are associated
with allele Z (MZ or ZZ). Serum levels greater
than 11 mmol/L appear to be protective
against emphysema. Emphysema develops in

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most (but not all) individuals with serum
levels less than 9 mmol/L.

^ [ Q: 1558 ] MRCPass - Basic Science

/ L --

* An 25 year old man has Duchenne's

muscular dystrophy.

What chances does his daughter's sons have
of inheriting the disease?

1 - 100 %

2- 50%

3- 25%

4- 10%

5- 0%

Answer & Comments

Answer: 2- 50%

Duchenne's muscular dystrophy is X linked.
This patient is affected (XxY). His wife is likely
to be unaffected (XX).

His daughters would all have the
chromosome (XxX)- all are carriers. Therefore
his daughter's sons will either have the
chromosome XxY or XY in 50% chances.

normal Xohrorrtisoms

SI & mi a I
fern alt

X chromosome wfo
mutation

x f

;;

Hit daughters flli sons arc
are carrier* normal

[ Q: 1559 ] MRCPass - Basic Science

# A 35 year old woman with a pruritic
■ash was diagnosed as having systemic
nastocytosis. Serum histamine was 2 ng/ml
normal: 0.3-1.0 ng/ml).

Which one of the following is true regarding
mast cells?

1- In mastocytosis there is insufficient mast
cells

2- Storage granules contain glucose

3- Storage granules contain histamine and
leukotrienes

4- It is an IgG mediated immune response

5- High temperature triggers mast cell release

Answer & Comments

Answer: 3- Storage granules contain
histamine and leukotrienes

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Mastocytosis is due to excessive mast cell
stimulation. Storage granules contain
histamine,leukotrienes, and lytic enzymes. It
leads to anaphylactic like states - urticaria,
flushing and also Gl symptoms such as
diarrhoea and nausea. Mast cells are Ig E
mediated but can be triggered by injury,
drugs and complement activation.

Cutaneous Mastocytosis

[ Q: 1560 ] MRCPass - Basic Science

Which one of the following
hormones is increased in hypogiycaemia?

1- Growth hormone

2- Insulin

3- Glucagon

4- Somatostatin

5- Thyroxine

Answer & Comments

Answer: 3- Glucagon

Glucagon secretion from the pancreas is
increased by amino acids arginine and
alanine, fasting (hypogiycaemia), stressful
stimuli. Glucagon is inhibited by
somatostatin.

Low Blood Sugar

Promotes

glucagon

release

Insulin L Glucagon
I™™ Feedback System

High Blood Sugor

Promotes

Insulin

release

Pancreas

Breakdown of
glycogen

Insulin

Pormafon of
glycogen

▼ T

More glucose Less glucose

In bloodstream In bloodstream

_I I_

[ Q: 1561 ] MRCPass - Basic Science

Reverse transcriptase PCR is used to
amplify which of the following?

1- Proteins

2- DNA

3- RNA

4- Ribosomes

5- Plasmids

Answer & Comments

Answer: 3- RNA

Reverse transcriptase PCR is a w ay to amplify
RNA. The RNA is transcribed into
complementary DNA (cDNA) using enzyme
reverse transcriptase. The cDNA is then
amplified by PCR.

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5 '

Tagged O/ ^
HCV &/
primer

No priming

(♦)-strand RNA

a = self priming
b = random priming
c = false priming

primer primer

5’ (-)-strand cDNA

♦

involves tumour suppressor genes?

1- Neurofibromatosis

2- Sarcoma

3- Down's syndrome

4- Adenomatous polyposis coli

5- Parkinson's disease

TAG PCR Downstream PCR

primer primer

(♦)-strand cDNA

Reverse Transcriptase PCR

Answer & Comments

Answer: 1- Neurofibromatosis

[ Q: 1562 ] MRCPass - Basic Science

An 25 year old man was admitted
with breathlessness. He has not been well for
a few days.

His arterial blood gases show :
pH 7.22
p0 2 15 kPa
pCo 2 3.2 kPa

bicarbonate 14.7 mmol/L
base excess -5.

What is this picture consistent with?

1- Acute asthma

2- Bulimia

3- Paracetamol overdose

4- Acute liver failure

5- Diabetic ketoacidosis

Two hits of the tumour suppressor genes are
required for loss of regulation (e.g. loss of
both NF-1 genes).

NF-1 gene in neurofibromatosis, BRCA-1 in
breast and ovarian cancer, Rb gene and the
VHL gene involve tumour suppressor genes.
The oncogene SRC is affected in sarcoma.

[ Q: 1564 ] MRCPass - Basic Science

The screening procedure in which on
antibody directed against a desired protein , is
used to examine bacterial transformants (for
the presence of a specific recombinant) is
referred to as a:

1- Me Fadden's blot

2- Southern blot

3- Northern blot

4- Western blot

5- Eastern blot

Answer & Comments

Answer: 5- Diabetic ketoacidosis

This patient has metabolic acidosis with
respiratory compensation. The low
bicarbonate and low pH suggests metabolic
acidosis. In order to compensate, the body
hyperventilates, blow ing off C02 and having
a relatively high p02.

[ Q: 1563 ] MRCPass - Basic Science
Which one of the following diseases

Answer & Comments

Answer: 4- Western blot

Western blot method uses antibodies to
examine proteins immobilized to a
membrane support.

Southern blot uses a nucleotide sequence
probe to examine DNA fragments separated
by gel electrophoresis, then transferred to
and immobilized on a membrane support.

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Northern blot uses a nucleotide sequence
probe to examine RNA immobilized to a
membrane support.

Eastern blot does not exist.

Protein Blot on SDS Polyacrylamide

Nitrocellulose Gel Electrophoresis

Label with Specific

Antibody

Detect Antibody

—

Reveals Protein
of Interest

* typhoid - oral

[ Q: 1566 ] MRCPass - Basic Science

Mutations in myosin have recently
been found to underlie the disease familial
hypertrophic cardiomyopathy.

Which one of the following regarding myosin
is correct?

1- It is not involved in striated muscle
contraction

2- Form filaments in a hexameric array of 2
heavy chains only

3- Myosin chain mutation is not associated in
familial hypertrophic cardiomyopathy

4- Carney complex is not a form of myosin
chain disorder

5- There are sites on myosin which allow for
ATP and actin binding

[ Q: 1565 ] MRCPass - Basic Science

fh -

# A 45 year old man who has a renal
transplant is on high dose long term steroids
and immunosuppression. He is about to
travel abroad and seeks vaccination advice.

Which one of the following vaccinations is
contraindicated in this man?

1- Yellow fever

Answer & Comments

Answer: 5- There are sites on myosin which
allow for ATP and actin binding

Myosin is involved in striated muscle
contraction.

It forms filaments in a hexameric array of 2
heavy chains and 2 pairs of light chains.

2- Haemophilus

3- Meningococcus

4- Tetanus toxoid

5- Diphtheria toxoid

Answer & Comments

Answer: 1- Yellow fever

The yellow fever is a live vaccine. These are
other examples:

* measles, mumps and rubella

Myosin heavy chain mutation is implicated in
familial hypertrophic cardiomyopathy. HOCM
and Carney complex are forms of myosin
chain disorders.

There are sites on myosin which allow for ATP

and actin binding.

* BCG

* poliomyelitis - oral Sabin vaccine

[ Q: 1567 ] MRCPass - Basic Science

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A 55 year old man has been diagnosed with
Burkitt's Lymphoma.

Which gene mutation is associated with this
condition?

1- BRAF

2- P53

3- C-myc

4- N-myc

5- Bcr-Abl

Answer & Comments

Answer: 3- C-myc

In Burkitt's lymphoma (associated with
Ebstein Barr virus), genetic translocations e.g.
t(8:14) lead to consequent c-myc
rearrangement and overexpression.

^ [ Q: 1568 ] MRCPass - Basic Science

t 1 - a — 1 —-

# A 18 year old girl has had a 3rd
presentation with meningocccal meningitis.
An immunologist suspects a problem with her
immune system.

Which of these are most likely to be
defective?

1- Macrophages

2- IgG or IgM

3- Neutrophils

4- Lymphocytes

5- Complement C5-9

Answer & Comments

Answer: 5- Complement C5-9

Neisseria infection leading to meningococcal
meningitis often occurs in patients with
complement deficiencies of C5-9.
Complements C5-C9 form the Membrane
Atttack Complex. Deficiencies in these
complements lead to depressed bactericidal
activity.

[ Q: 1569 ] MRCPass - Basic Science

A 30 year old man was admitted
with status epilepticus. He is given

intravenous diazepam.

Arterial blood gases on 15 l/min via reservoir
bag mask showed pH 7.05, paC0 2 8 kPa, pa0 2
15 kPa, and standard bicarbonate 16 mmol/l.

His other results were sodium 140 mmol/l,
potassium 4 mmol/l, and chloride 98 mmol/l.

What is the acid-base disturbance?

1- Hyperchloraemic metabolic acidosis

2- Normal anion gap metabolic acidosis

3- High anion gap metabolic acidosis

4- Low anion gap metabolic acidosis

5- Respiratory acidosis

Answer & Comments

Answer: 3- High anion gap metabolic acidosis

This patient had acidosis with both a high
PaC02 and a low standard bicarbonate--a
mixed acidosis. The anion gap was 30 mmol/l
(increased).

The Pa02 is lower than expected because the
patient was breathing around 70% oxygen.
This fits with the the clinical picture: he had a
lactic acidosis from prolonged fitting and a
respiratory acidosis from intravenous
diazepam.

[ Q: 1570 ] MRCPass - Basic Science

Which of the following tumour
suppresor genes is a tumour suppresor gene
involved in promoting apoptosis and
programmed cell death?

1- BRCA-1

2- P53

3- Bcl-2

4- Ras

5- Rb

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Answer & Comments

Answer: 2- P53

Ras is an oncogene. Bcl-2 inhibits rather than
promotes apoptosis.

Normal Celia.

p53 bi nds as a tetramer to activate
expression of growth-inhibitory genes

p53 binding Growth-inhibitory
si te ge me

Occasional Tumours:

deletion of one or
both p53 alleles

Reduced expression of
growth-inhibitory genes

p53 binding Growth-inhibitory
site gene

Various tumours:

No expression of
growth-inhibitory genes

Ml**

M utati ons r es ul ti mg i n p 53 bi ndi ng G rowt h i nh(bi tor y

t r u ncation or el teration si ^ m

p53 tumour suppressor gene

[ Q: 1571 ] MRCPass - Basic Science

Which one of the following is a
trinucleotide repeat disorder?

1- Fragile X syndrome

2- Duchenne's muscular dystrophy

3- Multiple Sclerosis

4- Klinefelter's syndrome

5- Turner's syndrome

Answer & Comments

Answer: 1- Fragile X syndrome

Fragile X syndrome, myotonic dystrophy,
Huntington's disease and Friedrich's ataxia
are trinucleotide repeat disorders.

[ Q: 1572 ] MRCPass - Basic Science

The parents of a child with cystic
fibrosis w ant to know the risk of their next
child being a carrier of the condition, risk of
the child being not affected or affected.

Which ONE of the following is the correct risk
for the child being only a carrier?

1 - 10 %

2- 25%

3- 50%

4- 75%

5- 100%

Answer & Comments

Answer: 3- 50%

Cystic Fibrosis has autosomal recessive
inheritance.

As both parents are carriers (AxA,BxB) of the
Cystic Fibrosis gene, then chances of another
child being affected (AxBx) is 1 in 4 (25%).

The chances of their child being free from the
CF gene (AB) is also 1 in 4 (25%).

The chances of a child being a carrier (AxB or
ABx) is 1 in 2 (50%).

Unaffected

"Carrier"

Father

Unaffected

"Carrier’'

Mother

■' u H f

Unaffected ’ CARRIER * CARRIER" Affected

l in 4 chance Lttaffected IMaffected l in 4 chance

1 in 4 chance 1 in 4 chance

[ Q: 1573 ] MRCPass - Basic Science
What form of virus is the herpes

1- Triple stranded RNA virus

2- Single stranded RNA virus

3- Single stranded DNA virus

4- Double stranded RNA virus

5- Double stranded DNA virus

virus?

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Answer & Comments

Answer: 5- Double stranded DNA virus
Herpes virus is a double stranded DNA virus.

[ Q: 1574 ] MRCPass - Basic Science

A 50 year old man complains of
visual loss. On examination, he has right sided
homonymous inferior quadrantinopia.

Which one of the following lesions is likely?

1- Left sided temporal area

2- Left sided parietal area

3- Occipital lobe

4- Optic chiasm

5- Optic nerve

Answer & Comments

Answer: 2- Left sided parietal area

A contralateral lower parietal lesion causes
lower homonymous quadrantinopia as
described.

[ Q: 1575 ] MRCPass - Basic Science
Western blotting is used to detect:

1- DNA

2- RNA

3- Protein

4- Antibodies

5- Enzymes

Answer & Comments

Answer: 3- Protein

Western blotting can be used to detect and
quantify proteins (e.g. bovine protein).

[ Q: 1576 ] MRCPass - Basic Science

Which one of the following features
is consistent with higher cortical involvement

rather than a diagnosis of a subcortical
lacunar stroke?

1- Ataxia

2- Dysarthria

3- Dysphasia

4- Pure motor features

5- Pure sensory symptoms

Answer & Comments

Answer: 3- Dysphasia

Evidence of higher cortical involvement, for
example - dysphasia, dyscalculia or or
disturbance of consciousness, would not be
consistent with a lacunar syndrome.

[ Q: 1577 ] MRCPass - Basic Science

Which one of the following blood
gas results may be an analytical error?

1- PH 7.6, paC0 2 - 2, p0 2 -13, Bicarbonate 30

2- PH 7.3, paC0 2 - 7, p0 2 -10, Bicarbonate 14

3- PH 7.5, paC0 2 - 8 , p0 2 -10, Bicarbonate 14

4- PH 7.5, paC0 2 - 6, p0 2 -12, Bicarbonate 26

5- PH 7.2, paC0 2 - 9, p0 2 9, Bicarbonate 12

Answer & Comments

Answer: 3- PH 7.5, PaC02 - 8, P02 - 10,
Bicarbonate 14

The patient has a high C02 and low
bicarbonate which would suggest
uncompensated respiratory acidosis, hence
the pH is too high to fit the scenario.

[ Q: 1578 ] MRCPass - Basic Science

Which of the following is amplified
by reverse transcriptase PCR?

1- RNA

2- Linear DNA

3- Circular DNA

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4- Glycoproteins

5- Reverse transcriptase enzyme

Answer & Comments

Answer: 4- Lactose

Answer & Comments

Answer: 1- RNA

Reverse transcriptase PCR is used to amplify
RNA, whilst conventional PCR is used to
amplify DNA.

[ Q: 1579 ] MRCPass - Basic Science

Adrenaline is a product of which
amino acid?

1- Arginine

2- Glutamine

3- Valine

4- Lysine

5- Tyrosine

Lactose is broken down into glucose and
galactose by an enzyme called lactase.

[ Q: 1581 ] MRCPass - Basic Science

A 75 year old lady has sudden
movements of her arm where she throws her
arm outwards, and uncontrollably injures
herself.

Which of the following areas could have
sustained an infarct?

1- Globus pallidus

2- Pontine nucleus

3- Corpus callosum

4- Subthalamic nucleus

5- Thalamus

Answer & Comments

Answer: 5- Tyrosine

Dopamine, adrenaline and noradrenaline are
derived from tyrosine via the intermediate
dopa.

Answer: 4- Subthalamic nucleus

Hemiballismus is caused by a subthalamic
nucleus lesion, which is commonly due to an
infarct.

rrr C00H

^^OOOH

~ HO rrv° OH

)

nh, 2

HC.AA 3 *

phenylalanine

tyrosine

L-p-(3,4-dlhydroxy-
pheny1)-a-alanine (Dopa)

dopamine

HO ' ^ " 2

(R>noradrenaline

(R)-adrenaline

Adrenaline synthesis

[ Q: 1580 ] MRCPass - Basic Science
Which one of the following breaks

down into Glucose and Galactose?

1- Ribose

2- Sucrose

3- Fructose

Subthalamic Nucleus

4- Lactose

5- Phosphofructose

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[ Q: 1582 ] MRCPass - Dermatology

{% -

* A 30 year lady presents has

erythema nodosum. She has a low grade
fever. There no recent history of travel
abroad.

Which of the following would be the most
appropriate investigation for this patient?

1- Colonoscopy

2- ESR

3- Upper Gl endoscopy

4- Chest x ray

5- Coxsackie viral serology

Answer & Comments

Answer: 4- Chest x ray

A chest x ray would help exclude sarcoidosis,
as most of the other causes are unlikely due to
the history. The causes of erythema nodosum
are streptococcal infection, acute sarcoidosis,
oral contraceptive pill, sulphonamides,
penicillins, inflammatory bow el disease, TB,
Behcet's Disease.

prognosis for malignant melanoma are the
tumour thickness, measured from the
overlying granular layer of the epidermis to
the deepest easily identifiable tumour cells -
the Breslow thickness, and the presence of
ulceration of the primary tumour.

Malignant melanoma

[ Q: 1584 ] MRCPass - Dermatology

r% -

A 23 year old student presents with
extensive, hypopigmented, scaly lesions on his
back and the chest.

^ [ Q: 1583 ] MRCPass - Dermatology

/ I---—--- 1

A 60 year old lady presents with a
nodular slightly pigmented skin lesion in her
left arm.

Which of the following change in the feature
suggests poor prognosis if it is malignant?

1- Increased diameter

2- Increased depth

3- Color

4- Shape

5- Consistency

Answer & Comments

Answer: 2- Increased depth

The features are suggestive of Malignant
melanoma. The main determinants of

The rash had been present for the last 1 year
and had gradually become more extensive.

He is otherwise well.

What is the treatment of choice?

1- Ketoconazole cream

2- Nystatin cream

3- Terbinafine cream

4- Oral terbinafine

5- Oral itraconazole

Answer & Comments

Answer: 1- Ketoconazole cream

The features are suggestive of Pityriasis
versicolor infection, a skin infection which
often presents as patches of relatively
depigmented skin. The cause is overgrowth of
the yeast Malassezzia furfur. If the skin is not

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tanned, the skin appears faw n with a slight
brawny scaling and wrinkling. It is slightly
itchy. It is usually a disease of young adults,
predominantly affecting the upper trunk.
Ketoconazole (topical) is the treatment of
choice.

[ Q: 1585 ] MRCPass - Dermatology

A 40 year old man presented to his
GP because of painful blisters on the backs of
his hands in the summer. He also had a similar
rash on the forehead. His hands, face and
forehead were covered with thick, wrinkled,
hyperpigmented skin. The patient's urine was
reddish orange.

Whot is the likely diagnosis?

1- Contact dermatitis

enzyme in porphyria cutanea tarda is
uroporphyrinogen decarboxylase.

Porphyria cutanea tarda

[ Q: 1586 ] MRCPass - Dermatology

A 45 year old man presents with
discrete, round, scaly, pigmented patches on
the back. Pityriasis versicolor is diagnosed by
the dermatologist.

Whot is the appropriate treatment?

1- Terbinafine

2- Prednisolone

3- Rifampicin

4- Ultraviolet light

5- Topical selenium sulphide

2- Pityriasis rosea

3- Epidermolysis bullosa

4- Pemphigoid

5- Porphyria cutanea tarda

Answer & Comments

Answer: 5- Porphyria cutanea tarda

In porphyria cutanea tarda, the urine
fluoresces pink to red. Porphyria cutanea
tarda's onset is typically during the fourth or
fifth decade of life. The disease tends to
develop, recur, or worsen during the spring
and summer, when exposure to sunlight is
greatest. Photosensitivity is the hallmark of
porphyria cutanea tarda. The deficient

Answer & Comments

Answer: 5- Topical selenium sulphide

Pityriasis versicolor (also called tinea
versicolor) is a skin infection caused by a
fungus called Malassezia furfur. Topical
antifungal medications - containing either
2.5% selenium sulfide or ketoconazole cream
can be used. Oral ketoconazole 200 mg daily
for 7 days can also be used. Other topical
antifungal agents such as clotrimazole,
miconazole or terbinafine are less widely
recommended.

^ [ Q: 1587 ] MRCPass - Dermatology

# A 45 year old patient had renal
transplantation 8 years ago. He is on regular

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immunosuppressive medication. He presented
with a large warty like growth on the back of
his buttocks.

What should be done next?

1- Observation

2- Skin biopsy

3- Stop immunosuppressives

4- Cryotherapy

5- Viral PCR

Answer & Comments

Answer: 2- Skin biopsy

Warts are caused by the human papilloma
virus, and tend to develop after 4 to 5 years
following transplantation. The risk of skin
cancer is increased especially in sun exposed
areas. Treatment of all warts are usually with
cryotherapy, However with this growth a
biopsy is necessary followed by possible
surgery.

[ Q: 1588 ] MRCPass - Dermatology

A 20 year old male, born of non-
consanguineous parents, was referred to our
department with complaint of the insidious
appearance of red-purple papules over the
trunk with occasionally itching and pin-point
bleeding, which had progressed over the past
4 years. These papules slow ly increased in
number and size. There was no history of
anhidrosis, abdominal or bone pain, acral
paresthesias, chest pain, or loss of visual
acuity.

On examination, Clusters of individual,
punctate, dark red to blue-black papules were
seen mainly over the anterior chest, back, and
hips.

What is the likely diagnosis?

1- Erythema multiforme

2- Erythema marginatum

3- Angiokeratoderma corporis diffusum

4- Cafe au lait spots

5- Neurofibromas

Answer & Comments

Answer: 3- Angiokeratoderma corporis

diffusum

Systemic angiokeratoma corporis diffusum
(Anderson-Fabry disease) is an unusual X-liked
lysosomal disorder characterized by deficiency
of ?-galactosidase. Onset of the disease
usually occurs during childhood or
adolescence with periodic crises of severe
pain in the extremities (acroparesthesias) and
the appearance of vascular cutaneous lesions
(angiokeratomas), hypohidrosis or anhidrosis,
and characteristic corneal and lenticular
opacities.

Angiokeratoderma corporis diffusum

[ Q: 1589 ] MRCPass - Dermatology

A 72 year old woman has developed
a rash over 6 weeks. On examination, there
were numerous fluid filled blisters over upper
and lower limbs as well as the trunk.

What is the likely diagnosis?

1- Pemphigus

2- Pemphigoid

3- Eczema

4- Psoriasis

5- Erythema nodosum

Answer & Comments

Answer: 2- Pemphigoid

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Pemphigoid is a disease of the elderly, rarely
presenting before 50 years of age.
Presentation is with large, tense, itchy blisters
on an erythematous base. They usually occur
on the upper arms and thighs and may spread
to the trunk. Lesions may be 2-5 cm in
diameter. They are thick walled and may last
for several days.

Bullous pemphigoid

[ Q: 1590 ] MRCPass - Dermatology

A 60 year old lady has developed an
uncomfortable venous ulcer on leg. On
examination, her leg is oedematous but
peripheral pulses are palpable. Doppler
ultrasound reveals no arterial disease.

Which one of the following is the most
appropriate management?

1- Leg elevation

2- Surgical debridement

3- Intravenous antibiotics

4- Compression dressing

5- Topical steroids

Answer & Comments

Answer: 4- Compression dressing

Compression helps to control painful sw elling
from fluid buildup (edema) and is recognized
as effective treatment for venous ulceration.

on her arms. Examination showed an
erythematous papular eruption with possible
pustules in the arm. There were burrows
between the fingers.

What is the diagnosis?

1- Molluscum contagiosum

2- Scabies

3- Dermatitis herpetiformis

4- Impetigo

5- Psoriasis

Answer & Comments

Answer: 2- Scabies

Scabies is spread by Sarcoptes scabei. It is
spread by contact only. Effective agents are
benzyl benzoate, ivermectin and permethrin
(Lyclear solution).

Scabies Rash

Scabies Mite

\h.

[ Q: 1591 ] MRCPass - Dermatology

A 58 year old woman was seen

[ Q: 1592 ] MRCPass - Dermatology

because of a three day history of itchy bumps

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A 50 year old woman has had ulcerative colitis
diagnosed 10 years ago. Over the last 5
months, she has developed an ulcer above the
medial malleolus. This is large has a necrotic
base and the edges are undermined.

How should it be managed?

1- Foam dressings

2- Debridement

3- Broad spectrum antibiotics

4- High dose steroids

5- Emmolients

Answer & Comments

Answer: 4- High dose steroids

The diagnosis is pyoderma gangrenosum
complicating ulcerative colitis. The initial
treatment should be with high dose steroids
orally and topical steroids. Methotrexate and
ciclosporin can also be used.

Pyoderma Gangrenosum

^ [ Q: 1593 ] MRCPass - Dermatology

o -

# A 35 year old man presented to his
general practitioner with a rash beginning
around the left ear and spreading into the
periorbital region. He was then referred
urgently to the hospital for assessment. The
patient had a history of atopic eczema (since
childhood), rhinitis, and asthma. He was taking
inhaled corticosteroids for asthma and had
last received a course of systemic steroids one
year previously. There were no risk factors for
HIV infection.

On examination he was alert, he was pyrexial
at 39.2°C, his pulse was 100 bpm, and his
blood pressure was 130/70 mm Hg. There was
a widespread erythematous rash covering his
face, chest, and arms, which was described as
wet with a yellow ish exudate. The rash
extended around both eyes, which could not
be opened.

What is the likely diagnosis?

1- Varicella zoster infection

2- Pityriasis versicolor

3- Psoriasis

4- Pemphigus

5- Eczema herpeticum

Answer & Comments

Answer: 5- Eczema herpeticum

Eczema herpeticum represents widespread
cutaneous HSV in patients with pre-existing
skin disorders. Eczema herpeticum is also
known as Kaposi's Varicelliform Eruption. The
patient often presents with clusters of
umbilicated vesicles appearing on abnormal or
even apparently normal skin. The eruption
then spreads over the following 7 to 10 days,
and the umbilicated vesicles evolve into classic
discrete "punched-out" small erosions.

Typically, the patient experiences fever,
malaise, and generalized lymphadenopathy.
The vesicles may breakdown and coalesce into
large erosions that have a tendency to be
complicated by secondary infection. The
course of this condition is usually 2 to 6
weeks. Recurrent episodes may occur, but the
clinical presentation is typically milder.

^ [ Q: 1594 ] MRCPass - Dermatology

# A 50 year old woman with atopic
eczema presented with worsening skin
symptoms of erythema and pruritus.

She had tried skin emmolients, and topical
betnovate.

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Which drug is most appropriate next?

1- Retinoids

2- Hydrocortisone

3- Coal tar

4- Cyclosporin

5- Minocycline

Answer & Comments

Answer: 4- Cyclosporin

The use of cyclosporin in Atopic Dermatitis has
been fairly well studied and a high percentage
of patients improve with therapy.

Atopic Eczema

[ Q: 1595 ] MRCPass - Dermatology

A 45 year old man who has been
exposed to the sun is complaining of a rash
with blistering on his hands, chest and
forehead. On examination, there were small
areas of excoriation around the rash.

What is the diagnosis?

1- Pustular psoriasis

2- Pemphigoid

3- Dermatitis herpetiformis

4- Porphyria cutanea tarda

5- Granuloma annulare

Answer & Comments

Answer: 4- Porphyria cutanea tarda

Patients with Porphyria Cutanea Tarda
develop liver damage and fragile skin and

fluid-filled blisters on the face, arms, hands
and other skin exposed to sun.

Blistering rash seen in porphyria cutanea tarda

[ Q: 1596 ] MRCPass - Dermatology

A 45 year old lady presents to the
dermatologist with target like lesions. The
circular lesions have a central blister.

Which one of the following is the most
common cause?

1- Pemphigoid

2- Herpes simplex

3- Mycoplasma

4- Vitamin C deficiency

5- Orf

Answer & Comments

Answer: 2- Herpes simplex

The lesions are erythema multiforme. The
commonest cause is quoted to be herpes
simplex, although all the others are also
causes.

Erythema Multiforme

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[ Q: 1597 ] MRCPass - Dermatology

/ -

* A 42 year old woman has developed

a rash on her face over a year and a half. The
rash is is erythematous and scaly. There are
areas of alopecia on the scalp.

What is the diagnosis?

1- Lupus pernio

2- Discoid lupus

3- Erythroderma

4- Dermatitis herpetiformis

5- Scabies

Answer & Comments

Answer: 2- Discoid lupus

Discoid lupus erythematosus is characterized
by inflammation and scarring type skin lesions
which occur on the face, ears and scalp. These
lesions develop as an inflamed growth with,
scaling and a warty like appearance. The
center areas may appear lighter in color
surrounded by an area darker than the normal
skin. When lesions occur in hairy areas such as
the scalp, permanent scarring and hair loss
can occur.

Discoid lupus

[ Q: 1598 ] MRCPass - Dermatology

A 42 year old man has been treated
by the GP for 2 days for presumed psoriasis
with topical betnovate.

However, his rash worsened and now presents
with severe erythema all over the body.

What treatment is recommended?

1- Oral steroid

2- Cooling with air

3- Topical tar

4- Topical steroids

5- Topical soft white paraffin

Answer & Comments

Answer: 5- Topical soft white paraffin

A patient with severe erythroderma should be
hospitalized for supportive care. Cooling is
done with intravenous fluids and regulating
room temperature. Emmolients should be
used. Steroids and topical tar preparations
should be avoided.

Erythroderma

[ Q: 1599 ] MRCPass - Dermatology

A 62 year old woman has a rash on
the trunk with concentric erythematous bands
forming a wood-grain appearance.

Which one of the following erythematous
conditions is associated with gastric
carcinoma?

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1- Erythema multiforme

2- Erythema ab igne

3- Erythema gyratum repens

4- Erythema nodosum

Answer & Comments

Answer: 4- Erythema nodosum

This is a description of erythema nodosum
related to inflammatory bow el disease.

5- Erythroderma

Answer & Comments

Answer: 3- Erythema gyratum repens

Eythema Gyratum Repens is associated with
malignancy in as many as 80% of patients.
Among visceral malignancies, the lung is the
most common site, followed by the breast,
urinary bladder, uterus and/or cervix, Gl tract
(stomach), and prostate.

Erythema Gyratum repens

[ Q: 1600 ] MRCPass - Dermatology

A 27 year old complained of
diarrhoea, abdominal pain and fever for the
past few days.

On examination there was a visible mouth
ulcer and anal skin tags. On the lower shin
there were red painful raised skin lesions.

Whot is the most probable diagnosis?

1- Behcet's disease

2- Pyoderma gangrenosum

3- Erythema multiforme

4- Erythema nodosum

5- Erythema marginatum

The fever, dirrhoea and abdominal pains may
be due to ulcerative colitis or Crohn's disease.

Erythema nodosum

[ Q: 1601 ] MRCPass - Dermatology

A 37 year old man presented to his
general practitioner with a rash beginning
around the right ear and spreading into the
periorbital region. He was known to have
eczema and also was HIV positive.

3 days later, he was systemically unw ell,
complaining of sweats and rigors. On
examination he was alert, he was pyrexial at
39.2°C, his pulse was 100 bpm, and his blood
pressure was 128/70 mm Hg. There was a
widespread erythematous rash covering his
face, chest, and arms. The rash extended
around both eyes, which could not be opened.
On closer inspection of the rash, it was
apparent that there were multiple small
vesicles 1-2 mm in diameter and shallow
ulcers over the face and periorbital region.

What is the likely diagnosis?

1- Dermatitis herpetiformis

2- Smallpox

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3- Tinea versicolor

4- Pemphigus vulgaris

5- Eczema herpeticum

Answer & Comments

Answer: 5- Eczema herpeticum

The diagnosis is consistent with eczema
herpeticum and probable secondary bacterial
infection. This is caused by HSV-1, and is more
common among immunosuppressed
individuals. Treatment is with aciclovir.

Eczema Herpeticum

[ Q: 1602 ] MRCPass - Dermatology

A 60 year old man presented with a
pruritic rash. Burrows were found on his arms
and in the web spaces of the fingers. He was
treated with Permethrin creams and
improved. 3 weeks later, he came to the
hospital again when the pruritus returned
suddenly.

What is the likely cause for this?

1- Allergy to Permethrin cream

2- Re-infection with scabies mites

3- Type 4 hypersensitivity to mite feces

4- Erythema multiforme

5- Dermatitis herpetiformis

Answer & Comments

Answer: 3- Type 4 hypersensitivity to mite
feces

A delayed type IV hypersensitivity reaction to
the mites, their eggs, or scybala (ie, packets of
feces) occurs approximately 30 days after
infestation. This reaction is responsible for the
intense pruritus that is the hallmark of the
disease. Individuals who already are sensitized
from a prior infestation can develop
symptoms within hours when exposed to any
allergens.

[ Q: 1603 ] MRCPass - Dermatology

A 40 year old HIV-infected man
comes in for routine care and evaluation of
skin lesions on his face. His most recent tests
showed a CD4 count of 38 cells/mm * 1 2 3 4 5 and HIV
RNA of 87,000 copies/ml. He is not compliant
on antiretroviral therapy. The patient
describes a 2-3 month history of persistent
papules on his fingers that have gradually
increased in number and size.

What is the likely diagnosis?

1- Molluscum contagiosum

2- Kaposi's sarcoma

3- Herpes zoster virus infection

4- Orf

5- Malignant melanoma

Answer & Comments

Answer: 1- Molluscum contagiosum

Molluscum contagiosum is caused by the DNA
pox virus. Papular lesions occur first followed
by macular lesions. Pruritus can occur, but
erythema or inflammation is uncommon
around the lesion. The lesion is present for
several weeks and is self limiting.

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[ Q: 1604 ] MRCPass - Dermatology

An 80 year old man complained of
bullous skin lesions on both the upper and
lower extremities. On examination there were

1-2 cm blistering lesions throughout the body.

What is the most probable diagnosis?

1- Pemphigus vulgaris

2- Erythema multiforme

3- Dermatitis herpetiformis

4- Bullous pemphigoid

5- Insect bite

Answer & Comments

Answer: 4- Bullous pemphigoid

Bullous pemphigoid is more common than
pemphigus , occurs more commonly in later
life (>60 years). Large bullae appears anyw
here on the skin ,they tend to be itchy and the
lesions are deep and mucosal involvement
rare. The reverse is true for pemphigus
vulgaris.

[ Q: 1605 ] MRCPass - Dermatology

A 30 year old woman presents with a
rash. The rash consists of erythematous
plaques, excoriations, and vesicles some of
which have ruptured leaving a crust. She has
had a past history of gluten sensitive
enteropathy.

What is the best treatment for the rash?

1- Prednisolone

2- Azathioprine

3- Dapsone

4- Calamine lotion

5- E45 cream

Answer & Comments

Answer: 3- Dapsone

Dapsone (diaminodiphenyl sulfone) and
sulfapyridine are the primary medications
used to treat Dermatitis Herpetiformis (DH).
Dapsone often is used initially; sulfapyridine is
substituted in patients unable to tolerate
dapsone.

Improvement may be dramatic; symptomatic
improvement of skin lesions often begins
within hours. Other, less effective, treatments
for DH include colchicine, cyclosporine, and
prednisone.

Dermatitis Herpetiformis

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^ [ Q: 1606 ] MRCPass - Dermatology

tl -

# A 14 year old girl has developed
ulcerated lumps on the back of his legs. She
has a previous history of tuberculosis.

Whot is the likely diagnosis?

1- Erythema multiforme

2- Erythema nodosum

3- Lupus erythematosus

4- Erythema induratum

5- Granuloma annulare

2- Prednisolone

3- UV B

4- Oral retinoids

5- Cryotherapy

Answer & Comments

Answer: 4- Oral retinoids

Due to its anti-inflammatory activity,
isotretinoin (retinoid) is an extremely effective
drug if given systemically in severe forms of
seborrhoea and acne.

Answer & Comments

Answer: 4- Erythema induratum

Erythema induratum is a chronic, recurring
panniculitis that is found predominantly on
the legs of women with tuberculin
hypersensitivity.

Erythema Induratum

[ Q: 1607 ] MRCPass - Dermatology

A 19 year old patient with acne
vulgaris has already been treated with a
course of minocycline, but the condition is not
responding well to treatment.

Whot treatment option should be considered
next?

1- Erythromycin

[ Q: 1608 ] MRCPass - Dermatology

A 52 year old man has recently
travelled back from South America 2 weeks
ago on holiday. He presents to the
dermatologist with a facial ulcer with
granulating base.

Whot is the likely diagnosis?

1- Behcet's disease

2- Cutaneous leishmaniasis

3- Syphilis

4- Basal cell carcinoma

5- Squamous cell carcinoma

Answer & Comments

Answer: 2- Cutaneous leishmaniasis

Cutaneous leishmaniasis is spread by female
sandflys of the genus Phlebotomus. The
causative agents include L. (V.) braziliensis, L.
(L.) mexicana, L. (V.) panamensis, and related
species. Most infections follow a bite from an
infected sandfly and remain subclinical.
However, in some cases, after an incubation
period of 1-12 weeks, a papule develops that
enlarges and ulcerates. The typical lesion are
crusty, painless ulcers on exposed skin.
Ulcerative lesions are usually shallow and
circular with well-defined, raised borders and
a bed of granulation tissue. Local
lymphadenopathy only occurs in the presence

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of bacterial superinfection. Cutaneous
leishmaniasis is found predominantly in South
America, Central Africa, around the
Mediterranean Sea and India.

[ Q: 1609 ] MRCPass - Dermatology

A 23 year old student presents with
extensive, hypopigmented, slightly scaly
lesions on his back and the chest.

itchy. It is usually a disease of young adults,
predominantly affecting the upper trunk.

Pityriasis Versicolor

[ Q: 1610 ] MRCPass - Dermatology

A 65 year old man, who received a
renal transplant 30 years ago, was evaluated
in clinic when he complained of a lump behind
his ear. He has been on ciclosporin and
tacrolimus. On physical examination he had an
ulcerated nodule behind the ear.

Whot is the likely diagnosis?

1- Seborrhoeic wart

The rash had been present for the last 1 year
and had gradually become more extensive.

He is otherwise well.

What is the treatment of choice?

1- Ketoconazole cream

2- Actinic keratosis

3- Squamous cell carcinoma

4- Basal cell carcinoma

5- Malignant melanoma

2- Nystatin cream

3- Terbinafine cream

4- Oral terbinafine

5- Oral itraconazole

Answer & Comments

Answer: 1- Ketoconazole cream

Answer & Comments

Answer: 3- Squamous cell carcinoma

Patients who have had renal transplants have
a 60 fold increased risk of squamous cell
carcinoma. Treatment is with radiotherapy,
surgical excision and reduction of
immunosuppression where possible.

Squamous cell carcinoma

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[Q: 1611] MRCPass -
Ophthalmology

A 65 year old woman with a chronic disease
has asymptomatic thinning of the sclera
through which the underlying uveal tissue can
be seen.

Which of the following diseases is most
strongly associated with scleromalacia
perforans?

1- Psoriasis

2- HIV

3- SLE

4- Rheumatoid arthritis

5- Wegener's granulomatosis

Answer & Comments

Answer: 4- Rheumatoid arthritis

Scleromalacia perforans is painless thinning of
the sclera. Vast majority of patients are
females with longstanding rheumatoid
arthritis (sero positive). It is rarely seen in
Behcet's and ulcerative colitis.

[Q: 1612] MRCPass -
Ophthalmology

A 25 year old woman presents with gritty
eyes. Her children have similar symptoms. On
examination, the conjunctivae are red and
swollen with a discharge which is crusting the
eyelashes.

What is the most likely diagnosis?

1- Keratoconjunctivitis sicca

2- Bacterial conjunctivitis

3- Anterior uveitis

4- Hay fever

5- Herpes simplex keratitis

Answer & Comments

Answer: 2- Bacterial conjunctivitis

The clinical presentation fits conjunctivitis
best. The most common organisms are
staphylococcus, streptococcus and
Haemophilus influenzae. Treatment is with
chloramphenicol eyedrops.

[Q: 1613] MRCPass-
Ophthalmology

A 25 year old female presents with a history of
headache, vomiting and blurred vision for the
last 2 weeks. Direct questioning reveals that
she is taking a tablet for her spots (acne). She
has a high BMI and bilateral papilloedema on
examination.

Which of the following investigations is most
likely to help confirm the diagnosis?

1- MRI brain

2- Copper studies

3- Anti Ach antibodies

4- CSF pressure measurement

5- Iron studies

Answer & Comments

Answer: 4- CSF pressure measurement

The diagnosis is Benign Intracranial
Hypertension (Pseudotumour Cerebri).

This is commoner in obese women of child
bearing age. It is also associated with the OCP,
steroid withdrawal, tetracyclines, headache,
nausea, visual symptoms and a Vlth cranial
nerve palsy.

CSF pressure is typically raised when lumbar
puncture is performed. Removal of CSF may
relieve the pressure and improve the visual
symptoms and headaches.

A 30 year old man presents with a 24 hour
history of blurred vision in left eye and mild
left frontal headache. He had a 15 year history

[Q: 1614] MRCPass-
Ophthalmology

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of diabetes mellitus. Examination of the left
eye visual field shows a central scotoma.

What is the likely diagnosis?

drops dilate the pupil by stimulating the
sympathetic system and should be used with
caution in adults with ischaemic heart disease.

1- Central retinal artery occlusion

2- Optic neuritis

3- Pituitary tumour

4- Hypertensive retinopathy

5- Diabetic retinopathy

Answer & Comments

Answer: 2- Optic neuritis

[Q: 1616] MRCPass -
Ophthalmology

A 60 year old man with a history of
hypertension presents with visual loss on the
right side. On examination he has visual loss
affecting the temporal field of his right eye
and the nasal field of his left eye.

Which of the following areas is likely to show
infarction on brain imaging?

A painful, more gradual onset visual 1- Left occipital lobe

impairment is consistent with optic neuritis. , n - u . .. ,, ,

r 2- Right occipital lobe

Occlusion of central retinal artery will result in
almost immediate loss of visual acuity in the
involved eye, usually without pain.

3- Right frontal lobe

4- Optic chiasm

5- Right temporal lobe

?il

1 J

[Q: 1615] MRCPass-

Ophthalmology

Answer & Comments

A 65 year old woman who has had a previous
myocardial infarction complains of a problem
with the vision in her left eye.

Prior to fundoscopy, the best agent to dilate
her pupils with is:

Answer: 1- Left occipital lobe

The patient has a right homonymous
hemianopia. Lesion is therefore behind optic
chiasm and most likely to be affecting the left
occipital lobe.

1- Phenylephrine 10%

2- Phenylephrine 2.5%

3- Cyclopentolate 1%

4- Tropicamide 0.5%

5- Tropicamide 1%

Answer & Comments

Answer: 5- Tropicamide 1%

Tropicamide (0.5% for children, 1% for adults)
is best for diagnostic purposes, dilating the
pupil for two to four hours by blocking the
parasympathetic terminals in the papillary
constrictor muscle.

Cyclopentolate works in a similar mode but
lasts for six to eight hours. Phenylephrine

[Q: 1617] MRCPass -
Ophthalmology

A 48 year old woman develops painful
bloodshot eyes.

Which one of the following features would
make scleritis more likely than iritis?

1- Pain which wakes her from sleep

2- Irregular pupil

3- Keratitis

4- Photophobia

5- Visual blurring

Answer & Comments

Answer: 1- Pain which wakes her from sleep

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Features of iritis are photophobia, visual
blurring, keratitic precipitates (best seen with
a slit lamp) and irregularity of the pupil.
Severe pain suggests scleritis and is not typical
of iritis or episcleritis (which is milder and
affects a smaller portion of the eye). In
scleritis, the pain can be so severe that it
disturbs sleep.

^ [Q: 1618] MRCPass -

S Ophthalmology

A 35 year old artist has painful eyes which
have been diagnosed as iritis by an
opthalmologist requiring steroid treatment.

Which of the following condition is a likely
couse?

1- Ankylosing spondylitis

2- Gallstones

3- Gout

4- Osteoarthritis

5- Pancreatitis

Answer & Comments

Answer: 1- Ankylosing spondylitis

Iritis (anterior uveitis) is found in all the
inflammatory conditions such as Behcet's
disease, Reiter's syndrome, ankylosing
spondylitis and sarcoidosis.

Iritis

[Q: 1619] MRCPass -
Ophthalmology

A 70 year man presents with sudden loss of
vision in his right eye, associated with a
relative afferent papillary defect. He has
poorly controlled hypertension and smokes.

Which of the following is likely?

1- Optic nerve compression

2- Optic neuritis

3- Chronic open angle glaucoma

4- Retinal vascular occlusion

5- Macular degeneration

Answer & Comments

Answer: 4- Retinal vascular occlusion

The history of acute loss of vision affecting
one eye suggests an acute vascular occlusion.
This is associated with an underlying disorder
such as glaucoma, hypertension, diabetes,
coagulation disorders, atherosclerosis, or
hyperlipidemia.

The visual loss after retinal vein occlusion is
variable. Haemorrhage may be present, and
the patient may be at risk for developing
glaucoma. In retinal artery occlusion, there is
a profound visual loss. The degree of loss is
related to the location of the occlusion. There
is also a further risk of stroke because the
emboli could be throw n off to other parts of
the brain.

^ [Q: 1620] MRCPass-

S Ophthalmology

A 45 year old man recently returned from a
holiday. He presents to A&E complaining of
disturbance in vision in his right eye.
Examination reveals a thickened ingrowth of
conjunctiva with prominent vessels which has
extended to overlie the cornea.

Which of the following is the most likely
diagnosis?

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1- Acute closure angle glaucoma

2- Behcet's disease of the eye

3- Conjunctivitis

4- Pterygium

Leber's hereditary optic neuropathy is a
mitochondrial disease, which affects the
retina. Patients may also develop ataxia and
cognitive changes. Fundoscopy is usually
limited in value.

5- Scleritis

Answer & Comments

Answer: 4- Pterygium

Gaucher's disease causes a pigmented retina,
Law rence Moon Biedl causes retinitis
pigmentosa, Multiple sclerosis causes a disc
pallor.

Pterygium is a raised, wedge-shaped growth
of the conjunctiva. It is most common among
those who live in tropical climates or spend a
lot of time in the sun. Symptoms may include
irritation, redness, and tearing. Pterygiums are
nourished by tiny capillaries that supply blood
to the tissue. As the pterygium develops, it
may alter the shape of the cornea, causing
astigmatism. If the pterygium invades the
central cornea, it is removed surgically.

A 18 year old man is referred with progressive
visual loss. He first noticed that reading had
become difficult, and then had difficulty
seeing further distances. On examination,
visual acuity is reduced to 6/18 bilaterally.
There are bilateral central scotomas
bilaterally, with loss of colour vision.
Fundoscopy is normal, apart from possibly
increased tortuosity of vessels.

What is the most likely diagnosis?

1- Diabetic retinopathy

2- Gaucher's disease

3- Leber's hereditary optic neuropathy

4- Lawrence Moon Biedl syndrome

5- Multiple sclerosis

[Q: 1621] MRCPass -
Ophthalmology

Answer & Comments

Answer: 3- Leber's hereditary optic

neuropathy

[Q: 1622] MRCPass -
Ophthalmology

A 18 year old man progressive visual loss. On
fundoscopy, there are multiple, dark, bone
corpuscles across the retina and pallor of the
optic disc. Examination of his visual fieldds
reveals peripheral field loss.

Which one of the following is most likely to be
the underlying diagnosis?

1- Diabetes

2- Hypertension

3- Retinoblastoma

4- Kearn Sayre's disease

5- Neurofibromatosis

Answer & Comments

Answer: 4- Kearn Sayre's disease

The clinical picture is consistent with retinitis
pigmentosa. Causes are:

■ Abetaliproteinaemia
Mitoschondrial diseases (Kearns
Sayre, CPEO)

■ Friedreich's and other cerbellar
ataxias

Law rence-Moon Syndrome (cognitive
impairment and obesity)

Bardet-Biedl Syndrome (syndactyly
and high BMI)

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^ [Q: 1623] MRCPass-

0 Ophthalmology

A 60 year old patient presents with a right
sided quadrantic hemianopia.

Which of the following conditions is likely to
couse this presentation?

1- A lesion of optic chiasm

2- Chloroquine poisoning

3- A lesion of occipital cortex

4- Alcohol

5- Diabetic retinopathy

Answer & Comments

Answer: 3- A lesion of occipital cortex

A partial occipital cortex insult (e.g. infarct)
may cause this. Lesions of the temporal and
parietal parts of the optic radiation can also
cause a quadrantic hemianopia. A lesion of
optic chiasm would cause a bitemporal
hemianopia. Chloroquine poisoning causes
symmetric bilateral scotomas.

[Q: 1624] MRCPass -
Ophthalmology

A 42-year-old man with a history of end-stage
renal disease, hypertension and hepatitis C
infection, was hospitalized with shortness of
breath. Chest XR showed left-sided pleural
effusion, and aspiration revealed an exudative
process. Pleural biopsy specimens showed
necrotic tissue with focal fibrosis,
noncaseating granulomas, and acid-fast bacilli.
Culture was positive for Mycobacterium
tuberculosis. Isoniazid (300 mg) orally and
pyrazinamide (2 g) after hemodialysis
sessions; vitamin B6 (50 mg) and Ethambutol
(15 mg/kg per day) were commenced.

Visual acuity testing before initiation of
treatment showed 20/20 vision in both eyes
and normal color vision. Three months later,

repeat testing showed revealed a best
corrected visual acuity of 20/200 with the
right eye and counting fingers at 4 feet with
the left eye. Automated visual field testing
results revealed a central scotoma with
inferior temporal quadrant defects in both
eyes.

What is the cause of visual deterioration?

1- Vitamin C deficiency

2- Hypertension

3- Ethambutol toxicity

4- Middle cerebral artery stroke

5- Hepatitis C

Answer & Comments

Answer: 3- Ethambutol toxicity

The diagnosis is toxic optic neuropathy. The
anterior visual pathway is susceptible to
damage from toxins or nutritional deficiency.
Ethambutol is one drug that commonly is
associated with toxic optic neuropathy. The
optic

neuropathy that occurs is dose dependent and
duration related. There is a reported incidence
of 1% - 5% of optic neuropathy with
ethambutol. Toxicity generally does not
develop until after treatment for at least 1.5
months.

Isoniazid, ethylene glycol and amiodarone are
other associated drugs. Causes of nutritional
optic neuropathy include tobacco, ethanol,
thiamine deficiency and vitamin B-12
deficiency.

A 25 year old man presents with blurring of
vision in his right eye. Examination reveals
visual acuity in the right eye of 6/18 and in the
left eye 6/6. Visual fields confrontation reveal
a right temporal visual field defect and partial

[Q: 1625] MRCPass -
Ophthalmology

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loss of the superior part of temporal field of
the left eye.

Where is the likely position of lesion
responsible this defect?

1- Retina

2- Optic nerve

3- Optic chiasm

4- Temporal lobe

5- Frontal lobe

Answer & Comments

Answer: 3- Optic chiasm

The likely localization of the lesion is around
the optic chiasm, spreading up the right optic
nerve. The signs indicate a bitemporal visual
field defect with involvement of the right optic
nerve (decreased visual acuity). An occipital
lobe lesion causes a congruous homonymous
hemianopia. A temporal lobe lesion causes an
upper homonymous quantranopia.

The diagnosis is sicca syndrome, which can be
caused by drugs tricyclic antidepressants, high
dose diuretics and (B-blockers. Sjorgens (anti
Ro Ab) and sarcoidosis (serum ACE) are
systemic causes.

^ [Q: 1627] MRCPass-

• Ophthalmology

^ m

A 30 year woman presents with 2 month's
history of episodic, brief visual loss affecting
the right eye. Over the last one year she had
gained a considerable amount of weight.
Examination reveals a BMI of 33, bilateral
optic disc sw elling, worse on the right and
small retinal haemorrhages on the right.

What is the likely diagnosis?

1- Sagittal sinus thrombosis

2- Benign intracranial hypertension

3- Optic neuritis

4- Graves eye disease

5- Pituitary tumour

A 30 year old woman has been having
increasing dryness and discomfort affecting
her eyes. On examination, her visual acuity is
normal in both eyes. There are early cataracts
visible in both lenses. The eyes appear red and
mildly inflamed bilaterally. An Schirmer's test
confirms that tear production is diminished.

What is the clinical diagnosis?

1- Hypopyon

2- Sicca syndrome

3- Conjunctivitis

4- Ectropion

5- Posterior uveitis

[Q: 1626] MRCPass -
Ophthalmology

Answer & Comments

Answer: 2- Sicca syndrome

Answer & Comments

Answer: 2- Benign intracranial hypertension

Benign intracranial hypertension is raised
intracranial pressure in the absence of a mass
lesion or of hydrocephalus. It usually occurs in
young obese females in their third or fourth
decade and is often idiopathic.

The condition appears to be due to impaired
CSF absorption from the subarachnoid space
across the arachnoid villi into the dural
sinuses. Drugs such as tetracyclines and oral
contraceptive pill are associated with the
condition.

[Q: 1628] MRCPass -
Ophthalmology

A 55 year old woman complains of severe pain
in her right eye. There is blurring of vision and
she feels nauseated and has vomited several

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times. Earlier in the day she has undergone
colonoscopy for evaluation of Crohn's disease.

What is the likely cause of her painful red eye?

1- Conjunctivitis

2- Episcleritis

3- Acute angle closure glaucoma

4- Anterior uveitis

5- Retinitis pigmentosa

Answer & Comments

Answer: 4- Foscarnet

The most frequent opportunistic infection that
involves the eye in AIDS is CMV retinitis which
is likely in this case. This is classically described
as a 'cheese and tomato on pizza' appearance.
Toxoplasma tends not to show haemorrhagic
changes. CMV retinitis can be treated with
ganciclovir and foscarnet.

Answer & Comments

Answer: 3- Acute angle closure glaucoma

Acute angle-closure glaucoma is caused by a
rapid increase intraocular pressure.
Anticholinergic agents are sometimes used
during endoscopy to cause smooth muscle
relaxation to aid examination when difficulty
is encountered. These agents cause pupillary
dilatation thus precipitating acute angle
closure glaucoma. Treatment can be with
miotic agents (pilocarpine) which contract
ciliary muscle, tightening the trabecular
meshw ork and allow increased outflow of the
aqueous. Topical beta-adrenergic receptor
antagonists (e.g. Timolol eye drops) decrease
aqueous humor production by the ciliary
body.

i_ y

A 55 year old man known to be HIV positive
presents with loss of vision. Fundoscopy
reveals yellow white patches with multiple
associated haemorrhages. In view of the likely
diagnosis, which of the following drugs would
be appropriate?

1- Zidovudine

2- Indinavir

3- Prednisolone

4- Foscarnet

5- Amphotericin B

[Q: 1629] MRCPass -
Ophthalmology

[Q: 1630] MRCPass -
Ophthalmology

A 20 year old lady develops a deterioration in
vision in her left eye over 2 days. She
complains of discomfort in the eye and thinks
that difficulty with perception of colour was
the first problem that she noticed. On
examination, visual acuity on the left is only to
light perception. The pupil appears dilated and
does not constrict to light, although does
when a torch is shone in the right eye.

What is the most likely diagnosis?

1- Anterior iscaemic optic neuropathy

2- Central retinal artery occlusion

3- Optic neuritis

4- Retinitis pigmentosa

5- Epiphora

Answer & Comments

Answer: 3- Optic neuritis

Optic neuritis is a cause of acute vision loss
but also is notew orthy because of its high
association with multiple sclerosis. Of patients
with multiple sclerosis, 15-20% initially
present with an episode of optic neuritis. The
classic clinical triad of optic neuritis includes
the following:

Loss of vision,

Eye pain,

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Dyschromatopsia (impairment of
accurate color vision)

[Q: 1631] MRCPass -
Ophthalmology

A 60 year old woman presents with headache,
photophobia, nausea and vomiting. She has
blurred vision in her left eye. On examination
on the left the eye is red, the pupil is oval and
fixed, and the cornea appears cloudy.

Visual acuity is poor.

What is the diagnosis?

1- Acute scleritis

2- Retinal haemorrhage

3- Keratoconjunctivitis sicca

4- Acute primary closed angle glaucoma

5- Primary open angle glaucoma

Answer & Comments

Answer: 4- Acute primary closed angle
glaucoma

The clinical features are characteristic of acute
primary closed angle glaucoma. With the
condition, eyeball feels hard on palpation. It
usually occurs in hypermetropic people with
small eyeballs in whom the anterior chamber
drainage angle is narrow . When the the iris
becomes apposed to the lens and prevents
the efflux of aqueous from the posterior
chamber, the drainage angle is

Once the acute attack has been broken, the
definitive therapy for narrow -angle glaucoma
is surgical. A peripheral iridotomy, surgical or
by laser therapy, is performed.

[Q: 1632] MRCPass -
Ophthalmology

A 30 year old lady has a dilated right pupil that
is poorly responsive to light in comparison to
the left.

Accomodation reflex is very sluggish. There is
no evidence of ptosis and eye movements are
normal. Further examination reveals absent
ankle jerks.

The cause of her dilated pupil is most likely to
be:

1- Multiple Sclerosis

2- Myotonic dystrophy

3- A right Holmes-Adie Pupil

4- A left Argyll-Robertson pupil

5- Horner's syndrome

Answer & Comments

Answer: 3- A right Holmes-Adie Pupil

Holmes-Adie pupil is a cause of anisocoria. It
affects young adults (2:1 females:male). The
affected pupil is enlarged, poorly reactive to
light and supersensitive to 0.1% pilocarpine.
Ability to accommodate is also impaired and
sluggish. The clue in this scenario is that it is
associated with the loss of tendon reflexes.

obstructed, resulting in a rapid rise in
intraocular pressure.

Emergency treatment is with agents to lower
intraocular pressure. Topical beta-adrenergic
antagonists such as timolol and betaxolol
decrease aqueous production. The carbonic
anhydrase inhibitor, acetazolamide, also
decreases aqueous production and should be
given in conjunction.

Argyll-Robertson pupil is seen in syphilis.
Pupils are bilaterally small and irregular. It is
unreactive to light but reactive to
accommodation.

^ [Q: 1633] MRCPass-

* Ophthalmology

A 20 year old man with learning difficulties has
acute blurring of vision in his right eye.
Examination reveals ectopia lentis.

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What is the likely diagnosis?

1- Pseudoxanthoma elasticum

break adhesions to the lens. Examples of pupil
dilators are cyclopentolate and atropine.

2- Ehlers Danlos syndrome

3- Marfan's syndrome

4- Metachromatic leukodystrophy

5- Homocystinuria

Answer & Comments

Answer: 5- Homocystinuria

Ectopia lentis/ subluxation of lens is
associated with Ehlers Danlos syndrome,
Marfan's syndrome, Refsum's disease and
homocystinuria. The presentation fits with
homocystinuria as the other diseases are not
associated with mental retardation.

Homocystinuric patients typically have fair
skin coarse hair, osteoporosis, mental
retardation (nearly 50%), seizure disorder,
marfanoid habitus and increased
thromboembolic risk.

[Q: 1634] MRCPass -
Ophthalmology

A 25-year-old male who is known to have
ankylosing spondylitis presents with a painful,
aching, photophobic red eye. Examination
shows cells floating in the anterior chamber
and precipitated on the back of the cornea.

What is the best treatment option?

1- Local steroids

2- Local steroids and a pupil dilator

3- Local steroids and a pupil constrictor

4- Chloramphenicol

5- Oral prednisolone

Answer & Comments

Answer: 2- Local steroids and a pupil dilator

The patient has anterior uveitis. Treatment
should be with local steroids and a dilator to

[Q: 1635] MRCPass -
Ophthalmology

A 25 year old man has an illness which is
associated with visual impairment.

Which of the following may be associated with
optic atrophy?

1- Anti GBM antibodies

2- Red Ragged fibres on muscle biopsy

3- Iron deposition on liver biopsy

4- Anti Thyroid antibodies

5- Anti Acetylcholinesterase antibodies

Answer & Comments

Answer: 2- Red Ragged fibres on muscle
biopsy

Most mitochondrial myopathies do have
ragged red fibers on the muscle biopsy.
Examples are Kearns Sayre disease, MELAS,
MERRF and Leber's optic atrophy. Kearn
Sayre's disease and Lebers are associated with
optic atrophy.

A 60 year old man is referred by a GP with
visual loss. The patient has noticed a gradual
deterioration in his vision over the last 3
months. Examination shows cupping of the
optic disc and intraocular pressure of 32
mmHg.

What is the diagnosis?

1- Kearns Sayre's disease

2- Cataract

3- Glaucoma

4- Episcleritis

5- Optic neuritis

[Q: 1636] MRCPass-
Ophthalmology

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Answer & Comments

Answer: 3- Glaucoma

Chronic (open angle) glaucoma is
characterised by a triad of:

-Visual field loss - typically initially supranasal,
but gradually extending

-Pathological cupping of the optic disc

Which of the following arteries, if diseased ' is
most likely to be the cause of his symptoms?

1- Anterior Cerebral

2- Basilar

3- Internal Carotid

4- Middle cerebral

5- Vertebral

-Raised intraocular pressure (>24 mmHg)

[Q: 1637] MRCPass -
Ophthalmology

What is the diagnosis?

1- Kearns Sayre's disease

2- Cataract

3- Glaucoma

4- Episcleritis

5- Optic neuritis

Answer & Comments

Answer: 3- Glaucoma

Answer & Comments

Answer: 3- Internal Carotid

The clinical scenario is amaurosis fugax.
Patients complain of a painless loss of part of
their vision lasting for a few minutes. This is
most commonly caused by emboli from the
carotid artery.

[Q: 1639] MRCPass -
Ophthalmology

A 50 year old man is seen annually at the
diabetic clinic. During one appointment, he
feels that vision has deteriorated somewhat.

Which one of the following fundoscopic
features, requires a referral for

opthalmological assessment?

1- Blot haemorrhages

2- Dot haemorrhages

3- New vessel formation

Chronic (open angle) glaucoma is
characterised by a triad of:

4- Microaneurysms

5- Hard exudates

Visual field loss - typically initially
supranasal, but gradually extending

■ Pathological cupping of the optic disc

■ Raised intraocular pressure (>24
mmHg)

Answer & Comments

Answer: 3- New vessel formation

The following are graded features of diabetic
retinopathy:

^ [Q: 1638] MRCPass-

% Ophthalmology

A 70 year old man gives a history of visual loss
affecting his right eye which lasted for
approximately 2 minutes.

Background - Micro aneurysms, dot and blot
haemorrhages, hard exudates Pre-
proliferative - Cotton wool spots, venous and
arteriolar changes in vessels, large
haemorrhages Proliferative - New vessel
formation Pre-proliferative retinopathy

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requires opthalmological assessment for early Still's disease

signs of proliferative retinopathy.

Reiters'syndrome

[Q: 1640] MRCPass -
Ophthalmology

A tall 30 year old man has upward dislocation
of lens on examination of his left eye.

Which disease is he most likely to have?

1- Homocystinuria

2- Marfan's syndrome

3- Myotonic dystrophy

4- Ehlers-Danlos syndrome

5- Pseudoxanthoma elasticum

Answer & Comments

Answer: 2- Marfan's syndrome

Ankylosing spondylitis

Behcet's disease

Sarcoidosis

Tuberculosis

Leprosy

Syphilis

[Q: 1642] MRCPass -
Ophthalmology

A 30 year old woman is unable to see the
peripheral part of the vision.

Which one of the following causes peripheral
visual loss?

Upward lens dislocation occurs in Marfan's
syndrome. downward dislocation is
commoner in homocystinuria.

/■—1

A 50 year old woman presents with a
unilateral painful red eye associated with
blurred vision, photophobia and watering. On
examination there are keratitic precipitates
and pupillary irregularity.

What is this clinical picture consistent with?

[ Q: 1641 ] MRCPass -
Ophthalmology

1- Papilloedema

2- Hereditary familial optic atrophy

3- Syphillitic optic atrophy

4- Retinitis pigmentosa

5- Retrobulbar neuritis

Answer & Comments

Answer: 4- Retinitis pigmentosa

Retinitis pigmentosa causes peripheral visual
loss (tunnel vision).

1- Ectropion

Central Scotoma causes are:

2- Acute closed angle glaucoma

3- Anterior uveitis

4- Posterior uveitis

5- Retinitis pigmentosa

Hereditary familial optic atrophy
Syphillitic optic atrophy
Papilloedema
Retrobulbar neuritis

Answer & Comments

Answer: 3- Anterior uveitis

The clinical features suggest anterior uveitis.
Causes are :

[ Q: 1643 ] MRCPass -
Ophthalmology

A 30 year old diabetic patient has intermittent
blurring of vision.

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What is the likely couse?

1- Maculopathy

2- Cataract

3- Neovascularisation

4- Refractory changes in the lens

5- Vitreous haemorrhage

[ Q: 1645 ] MRCPass -

Answer & Comments

\n\

Ophthalmology

Answer: 4- Refractory changes in the lens

Hyperglycaemia can cause refractory changes
in the lens, which is most likely to cause
blurred vision which is intermittent.

A 65 year old man suddenly loses all vision in
one eye. It begins to improve 15 minutes later
and is normal by 3 hours.

The most likely diagnosis is:

[Q: 1644] MRCPass -
Ophthalmology

A 66 year old man has a dilated left pupil, left
sided ptosis and limited movement consistent
with a third nerve palsy.

1- Retinitis pigmentosa

2- Vitreous haemorrhage

3- Retinal arterial occlusion

4- Retinal detachment

5- Retinal vein occlusion

Which one of the following is the likely couse?

1- Motor neuron disease

2- Crohn's disease

3- Wilson's disease

4- Aneurysm of the posterior communicating
artery

5- Cluster headache

Answer & Comments

Answer: 4- Aneurysm of the posterior
communicating artery

lllrd nerve palsy is caused by aneurysm of the
posterior communicating artery. Opthalmic
migraine is a rare cause of lllrd nerve palsy.

Answer & Comments

Answer: 3- Retinal arterial occlusion

Complete unilateral loss of vision, even if only
in part of the field of vision, is likely to be due
to an arterial event. This can be in the retina,
either amaurosis fugax or a with a CVA.

Retinal transient ischaemic attacks are usually
brief (<30 mins) and almost alw ays due to an
embolic event, most typically from the
ipsilateral carotid bifurcation. Occlusion of the
retinal vein can present acutely, although not
as abruptly as an arterial event, and the loss of
vision is not transient.

[Q: 1646] MRCPass -
Ophthalmology

A 35 year old woman with blurred vision and
pain in her right eye. Examination of the
cornea with fluorescein reveals a branching
ulcer.

Whot is the most likely diagnosis?

1- Herpes zoster ophthalmicus

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2- Herpes simplex keratitis

3- Conjunctivitis

4- Anterior uveitis

5- Scleritis

Answer & Comments

Answer: 2- Herpes simplex keratitis

The signs are consistent a partial 3rd nerve
palsy associated with periorbital pain. In a
young person a posterior communicating
artery aneurysm is a likely cause.

It is important to realise that frequently a III
nerve palsy is incomplete so the extent that
individual clinical features is seen may vary
with the following features:

Keratitis (corneal inflammation) can result
from a wide variety of infections.

Inflammatory cell infiltration and oedema
results in photophobia, pain and impaired
visual acuity with localised

corneal opacity. Permanent blindness can
occur if treatment is delayed. Herpes simplex
infection causes a characteristic branching
(dendritic) ulcer that may be seen with
fluorescein or rose bengal. Treatment is with
topical acyclovir.

[Q: 1647] MRCPass -
Ophthalmology

A 40 year old woman is referred for
assessment of a painful right eye which has
been progressive over a week.

On examination she has a mild ptosis of the
right eye. She was aw are of diplopia and had
vertical image separation on looking upwards.
She also had weakness of elevation of right
eye.

Which of the following is the likely diagnosis?

1- Neurosyphillis

2- Myasthenia Gravis

3- Cavernous sinus thrombosis

Ptosis

Loss of upward, downward and medial
movement of the affected eye

Lifting the eyelid reveals a divergent
strabismus and a dilated non-reactive pupil

The eye is in a 'down and out' position

Painful oculomotor palsy (pupil generally
involved) can be caused by:

1) Compression

Intracranial aneurysm, Uncal herniation,
Tumours (e.g. carcinomatous lesions of the
skull base, parasellar neoplasms), Epidermoid
cyst, Granuloma (Tolosa-Hunt, Sarcoid)

2) Infection

Meningitis, Encephalitis, Herpes zoster

3) Vascular disease

SLE, Temporal arteritis, Opthalmoplegic
Migraine, Dural cavernous sinus fistula

4) Infiltration

Leptomeningeal carcinoma, Neurofibroma

5) Demyelination

6) Trauma

4- Sphenoid sinusitis

5- Posterior communicating artery aneurysm

Answer & Comments

Answer: 5- Posterior communicating artery
aneurysm

[Q: 1648] MRCPass -
Ophthalmology

In diabetic involvement of the eye, which one
of the following can result in visual
impairment?

1- Lipaemia retinalis

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2- Rubeosis iridis

3- Glaucoma

4- Retinitis Pigmentosa

5- Drusen

Answer & Comments

Answer: 2- Rubeosis iridis

Retinal detachment, cataract, rubeosis iridis
and retinal vein occlusion are diabetic eye
involvement manifestations. Lipaemia retinalis
is the milky appearance of retinal vessels in
patients with hypertriglyceridaemia. It does
not cause impaired vision.

A 45 year old woman presents with a 24 to 48-
hour history of a red and aching eye with
photophobia. Vision in that eye is blurred, but
acuity is not significantly affected. On
examination there is sediment at the bottom
of the anterior chamber (hypopyon).

What is the diagnosis?

1- Scleritis

2- Keratitis

3- Iritis

4- Conjunctivitis

5- Episcleritis

[Q: 1649] MRCPass -
Ophthalmology

Answer & Comments

Answer: 3- Iritis

Iritis typically presents with symptoms of a
red, aching eye with photophobia, which
tends to worsen over hours to a few days.
Vision may be blurred, but acuity is not
severely affected.

The pupil tends to be small and may be
irregular. Hypopyon is an accumulation of
inflammatory cells in the anterior chamber

that produces a layered meniscus in the
inferior anterior chamber. It can accompany
severe iritis.

Iritis is associated with ankylosing spondylitis,
Reiter syndrome, sarcoidosis, inflammatory
bow el disease, and psoriasis.

^ [Q: 1650] MRCPass-

* Ophthalmology

A 35 year old Afro-Caribbean woman presents
with a history of fatigue, widespread joint
pains and shortness of breath with a dry
cough. Her ears and sinuses have been
normal, but she mentions that she has
recently attended the local eye casualty
department with a painful, photophobic red
eye. This was successfully treated with
Maxidex drops hourly during the day and
night.

The most likely diagnosis is:

1- Sarcoidosis

2- Ankylosing spondylitis

3- Wegener's granulomatosis

4- Ulcerative colitis

5- Rheumatoid arthritis

Answer & Comments

Answer: 1- Sarcoidosis

The presentation of a painful red eye,
especially with photophobia, and treatment
with frequent and potent topical
corticosteroid (Maxidex is dexamethasone
0.1%) together with pupillary dilatation,
strongly suggests a slit-lamp diagnosis of acute
iritis (anterior uveitis).

Common causes of iritis are:

■ Ankylosing spondylitis

■ Reiter's syndrome

■ Inflammatory bow el disease
Sarcoidosis

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The history and background is suggestive of
sarcoidosis.

2- Klinefelter's syndrome

3- Ehler Danlos

Wegener's granulomatosis may account for
the non-specific systemic features, but uveitis
is a much less common association than acute
scleritis.

^ [Q: 1651] MRCPass -

( Ophthalmology

A 65 year old diabetic woman complains that
her reading vision has become distorted in
one eye and the image appears smaller than
with the other eye. She has been diabetic for
20 years. Her glycaemic control has been
moderate for a long time. She does not
smoke.

Whot is the diagnosis?

1- Proliferative diabetic retinopathy

2- Complication of oral hypoglycaemics

3- Cataract

4- Diabetic maculopathy

5- Retinal artery occlusion

Answer & Comments

Answer: 4- Diabetic maculopathy

Symptoms visual distortion and small images
(micropsia) are typical of diabetic
maculopathy, but not typical of proliferative
retinopathy. The underlying pathology is due
to photoreceptors within the deeper layers of
the retina become irregularly spaced.

[Q: 1652] MRCPass -
Ophthalmology

A 20 year old man with learning difficulties is
brought for review by his worried parents
after he complained of visual blurring.
Examination with a slit lamp reveals ectopia
lentis.

Whot is the most likely diagnosis?

1- Marfan's syndrome

4- Homocystinuria

5- Fragile X syndrome

Answer & Comments

Answer: 4- Homocystinuria

Ectopia lentis/ subluxation of the lens is
associated with Ehlers Danlos syndrome,
Marfan's syndrome and homocystinuria.
There is downw ards lens dislocation in
homocystinuria. It is also more likely to be
associated with learning difficulties than
Marfan's syndrome.

Lens Dislocation

[Q: 1653] MRCPass-
Ophthalmology

A 60 year man with a history of Diabetes
Mellitus and hypertension attends an eye
clinic. On fundoscopy he is diagnosed to have
preproliferative diabetic retinopathy.

Which of the following is chorocteristic of
preproliferative diabetic retinopathy?

1- Microaneurysms

2- Hard Exudates

3- New vessels formation

4- Macular Odema

5- Venous Beading

Answer & Comments

Answer: 5- Venous Beading

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The stages of diabetic retinopathy are
background, preproliferative, proliferative and
end-stage. Microaneurysms, hard exudates
and macular oedema suggest background
diabetic retinopathy. Venous beading, soft
exudates and cotton wool spots are
associated with preproliferative diabetic
retinopathy.

[Q: 1654] MRCPass -
Ophthalmology

A 45 year old man presents to the
opthalmologist with an acute history of pain
and blurring in the right eye.

Examination reveals a visual acuity of 6/36 in
right eye and 6/6 in left eye. There is a central
scotoma in the right eye, and a swollen optic
disc on the right.

What is the diagnosis?

1- Pituitary tumour

2- Cavernous sinus thrombosis

3- Optic neuritis

4- Retinal haemorrhage

5- Retinal vein occlusion

Answer & Comments

Answer: 3- Optic neuritis

The acute presentation of central scotoma,
reduced visual acuity, a swollen optic disc is
likely to be due to optic neuritis. This is a
common visual presentation of a patient with
multiple sclerosis.

[Q: 1655] MRCPass -
Ophthalmology

A 40 year old woman with type 1 diabetes
mellitus presents for assessment.

Which one of the following features on
fundoscopy requires an urgent referral to an
ophthalmologist?

1- Pigmentation

2- Hard exudates in macular region

3- Soft exudates

4- Asteroid bodies

5- Microaneurysms

Answer & Comments

Answer: 2- Hard exudates in macular region

Urgent referral to an ophthalmologist (seen
within one week) is required if there is
proliferative retinopathy or if there evidence
of clinically significant macular oedema (hard
exudates at fovea). Microaneurysms signify
background diabetic retinopathy and soft
exudates signify preproliferative retinopathy.

[Q: 1656] MRCPass-
Ophthalmology

A 50 year old man has a painful right eye.

Which ONE of following diagnoses is
associated acute iritis?

1- Colorectal Cancer

2- Pseudoxanthoma elasticum

3- Psoriatic arthropathy

4- Keratoconus

5- Refsum's disease

Answer & Comments

Answer: 3- Psoriatic arthropathy

Iritis is associated with conditions such as
Reiter's syndrome, Behcet's disease. Psoriatic
arthropathy (about 20%) and inflammatory
bow el disease.

[Q: 1657] MRCPass-
Ophthalmology

A 55 year old man with diabetes finds that the
vision in one eye is blurred when he reads, but
not at other times.

The most likely diagnosis is:

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1- Retinal haemorrhage

2- Glaucoma

3- Macular oedema

4- Cataract

5- Optic neuritis

Answer & Comments

Answer: 3- Macular oedema

Answer & Comments

Answer: 4- Benign intracranial hypertension

The history of a lady with high BMI and
papilloedema is consistent with benign
intracranial hypertension. Vision may be
affected with enlargement of blind spot and
there are visual obscuration with movements
which provoke a rise in intracranial pressure
(eg. bending).

The macula is the area of retina surrounding
fovea. It is responsible for most vision.

Visual impairment more marked for reading
than distance is very suggestive of macular
disease, and the likely cause of symptoms in
this case is diabetic maculopathy, when the
central fovea becomes affected by retinal
oedema or frank hard exudate. Cystic macular
oedema (CME) occurs commonly after eye
surgery and is also called Irvine-glass
syndrome.

[ Q: 1659 ] MRCPass - Ophthalmology

A 45 year old patient has small unreactive
pupils.

Which one of the following causes small
pupils?

1- 3rd nerve palsy

2- Syphilis

3- Retrobulbar neuritis

[ Q: 1658 ] MRCPass - Ophthalmology

A 20 year old girl presents with a three week
history of headache and horizontal diplopia on
far right lateral gaze.

On two separate occasions she noted dimmed
vision whilst bending forw ards. Over the last
year she had gained 12 kilograms in weight.
On examination, her weight was 100 kg and
height 160 cm. Neurological examination
reveals bilateral papilloedema and a partial
right sixth cranial nerve palsy.

What is the likely diagnosis?

1- Multiple sclerosis

2- Craniopharyngioma

3- Graves eye disease

4- Benign intracranial hypertension

5- Sagittal vein thrombosis

4- Adie syndrome

5- Young age

Answer & Comments

Answer: 2- Syphilis

Syphilis causes Argyll Robertson pupil - small
and iregular pupils which do not react to light
because they are already small, [mnemonic:
ARP: Accomodation Reflex Present, PRA:
Pupillary Reflex Absent]

Dilated pupils occur in lllrd nerve palsy and
Holmes Adie pupil. Holmes Adie is also called a
myotonic pupil due to the slow reaction and is
associated with diminished tendon reflexes.

[ Q: 1660 ] MRCPass - Ophthalmology

A 55 year old woman presents with a 5 hour
history of severe pain over her left eye,
associated with loss of vision. Examination

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reveals an oval, partly dilated unreactive pupil
with hyperaemia of the ciliary vessels.

Which of the following is the likely diagnosis?

1- Pterygium

2- Scleritis

3- Acute (closed angle) glaucoma

4- Grave's opthalmopathy

5- Conjunctivitis

Answer & Comments

Answer: 3- Acute (closed angle) glaucoma

Acute glaucoma is a medical emergency. It is
usually unilateral but the other eye is often
affected within a few weeks of initial
presentation. The condition progresses over a
few hours and if treatment is delayed,
permanent blindness may result. Initial
management is with intravenous
acetazolamide (to reduce aqueous
production) and pilocarpine drops (to
constrict the pupil and so open the angle of
the anterior chamber). Definitive treatment is
with surgical iridectomy or laser iridotomy.

[ Q: 1661 ] MRCPass - Ophthalmology

A 70 year lady who a history of anxiety
presents with a 2 day history of severe left
temporal headache radiating from eye scalp.
She had also experienced discomfort during
eating.

Which one of following drugs should be given
this patient while awaiting diagnostic tests?

1- Prednisolone

Answer & Comments

Answer: 1- Prednisolone

The history suggests temporal arteritis (TA).
Vision loss is an important finding. About one
fifth of patients with TA and vision loss have
no systemic symptoms of TA. Treatment of
patients with TA is critical to avoid vision loss,
and therapy should be initiated based on
clinical suspicion, not biopsy results. The initial
prednisolone dosage should be between 60 to
100 mg per day. Usually, steroid therapy can
be discontinued within one year, although
some patients need prednisone therapy for
years.

An American College of Rheumatology study
determined that highly sensitive parameters
for diagnosis of TA are:

age more than 50 years

an ESR of more than 50 mm per hour

an abnormal temporal artery biopsy

[ Q: 1662 ] MRCPass - Ophthalmology

A 60 year old man presents with a six week
history of blurring of vision. His investigations
show a fasting plasma glucose of 15.

What is the likely cause of his blurred vision?

1- Osmotic changes in the lens

2- Maculopathy

3- Retinal aretery thrombosis

4- Cataract

5- Proliferative diabetic retinopathy

2- Diazepam

3- Sumatriptan

4- Ibuprofen

5- Carbamazepine

Answer & Comments

Answer: 1- Osmotic changes in the lens

The patient is a new ly diagnosed diabetic and
hence proliferative retinopathy is unlikely.
Retinal artery thrombosis would cause very
sudden onset symptoms. With this history,

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osmotic changes due to hyperglycaemia is
most likely to cause the visual symptoms.

[ Q: 1663 ] MRCPass - Ophthalmology

A35 year old woman develops an acutely
painful left red eye which woke her from
sleep. She is not on any medications. On
examination, her left eye appears red and is
watering profusely. Visual acuity is reduced to
6/18 in the left eye, but is normal in the right.
The pupil is contracted on the left side with a
reduced light reflex. The lens appears cloudy
and the iris appears hyperaemic.

What is the most likely cause of her red eye?

1- Maculopathy

2- Conjunctivitis

3- Acute iridocyclitis

4- Acute glaucoma

5- Corneal ulceration

Answer & Comments

Answer: 3- Acute iridocyclitis

Iridocyclitis, also known as anterior uveitis, is a
condition in which the uvea of the eye is
inflamed. Diagnosis of iridocyclitis is suggested
by the acute painful red eye, abnormal iris,
contracted pupil and reduced light reflex. It
can be effectively treated with tropane
alkaloids or steroids.

[ Q: 1664 ] MRCPass - Ophthalmology

A 50 year old man was diagnosed with
hypertension 10 years ago. He has symptoms
of some blurred vision since 1 week ago and is
assessed at the eye clinic.

Which of the following fundoscopic features
suggest a diagnosis of grade IV hypertensive
retinopathy>

1- New vessel formation

2- Swollen discs

3- Arterio-venous nipping

4- Haemorrhages

5- Cotton Wool spots

Answer & Comments

Answer: 2- Swollen discs

Grading of Hypertensive Retinopathy can be
done as follows:

I - Arteriolar Attenuation

II - AV nipping

III - Cotton wool spots and haemorrhages

IV - Disc Sw elling (papilloedema)

[ Q: 1665 ] MRCPass - Ophthalmology

A 35 year old woman reports that vision in her
right eye has become blurred over a few days.
Her right eye also feels painful. Examination
reveals relative afferent papillary defect.

The most likely diagnosis is:

1- Ischaemic optic neuritis

2- Retinal detachment

3- Retinal haemorrhage

4- Foveal oedema

5- Demyelinating optic neuritis

Answer & Comments

Answer: 5- Demyelinating optic neuritis

Painful symptoms would fit with optic neuritis.
Reduced visual acuity (to variable degree),
relative afferent papillary defect and
fundoscopy may reveal a swollen optic nerve
disc.

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[ Q: 1666 ] MRCPass - Ophthalmology

A 46 year old man with no previous visual
problems presents with an acute, severely
painful red eye.

What is the likely couse?

1- Optic neuritis

2- Optic atrophy

3- Retinal detachment

4- Vitreous haemorrhage

5- Angle closure glaucoma

Answer & Comments

Answer: 5- Angle closure glaucoma

Acute closed-angle glaucoma is an ocular
emergency that requires immediate diagnosis
and treatment to prevent permanent visual
impairment and to relieve pain. There is
sudden onset of blurred vision, eye pain and
redness. There is elevated intraocular
pressure of 40-80 mm Hg (normal <25 mmHg).

Topical beta-adrenergic antagonists such as
timolol and betaxolol decrease aqueous
production. The carbonic anhydrase inhibitor,
acetazolamide, also decreases aqueous
production. A drop of pilocarpine 2-4% every
15 minutes for the first 1-2 hours helps to
facilitate aqueous outflow .

Fundoscopy in glaucoma showing increased

cup to disc ratio

[ Q: 1667 ] MRCPass - Ophthalmology

A 65 year old miopic woman presents with
severe pain and reduced vision in her left eye.
She also reports seeing 'haloes' around most
objects. On examination, the eye is inflamed,
the pupil is dilated and acuity is markedly
reduced.

Which of the following is the most appropriate
test?

1- MRI brain

2- CT orbits

3- Intraocular pressure measurement

4- Lumbar puncture and CSF pressure

5- Schirmer's test

Answer & Comments

Answer: 3- Intraocular pressure measurement

The diagnosis is primary angle closure
glaucoma (acute).

The condition affects females more than
males and long-sighted patients are more
affected. There may be abrupt increases in
intraocular pressure, with watering of the eye
and loss of vision. Symptoms of eye pain,
nausea and abdominal pain, reduced visual
acuity, red eye and cloudy cornea can occur.
The pupil may be oval, fixed and dilated.

Treatment is with medical therapy
(acetazolamide, pilocarpine and betablockers)
followed by iridectomy.

[ Q: 1668 ] MRCPass - Ophthalmology

A 45 year old man reports that his vision has
gradually become blurred, especially in the
right eye. He is finding it difficult to read, even
in bright light, and has great difficulty when
driving at night because of glare from
oncoming headlights. He had a renal

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transplant 10 years ago and has been on low
dose maintenance immunosuppression and
antihypertensives. His mother also had renal
failure and glaucoma.

Whot is the diagnosis?

1- Cataract

2- Glaucoma

3- Scleritis

4- Retinitis pigmentosa

5- Visual impairment related to renal failure

Answer & Comments

Answer: 1- Cataract

Cataract is relatively common in renal
transplant patients, as risk factors include
renal failure and long-term systemic
corticosteroid medication. The symptoms are
when vision becomes worse in bright light
when the pupil constricts, confining the light
path to the central part of the lens where it is
thickest. This patient may have steroid
induced cataract.

Retinitis pigmentosa (RP) can occur in some
types of renal failure, especially Alport's
syndrome, associated with deafness and a
positive family history. The main symptom in
RP is poor night vision. Glare is less typical and
symptoms are progressive from a relatively
early age. Glaucoma causes gradual loss of
visual field and is rarely symptomatic in
middle age.

that her reflexes are all diminished. Her eye
movements are normal and there is no ptosis.

Whot is the most likely couse of the pupillary
abnormality?

1- Right third cranial nerve palsy caused by
posterior communicating artery aneurysm

2- Argyll-Robertson pupil on the left

3- Physiological state

4- Left sided Horner's syndrome

5- Holmes-Adie pupil on the right

Answer & Comments

Answer: 5- Holmes-Adie pupil on the right

There is very slow reaction and incomplete
reaction to light and sluggish accommodation.
Once the pupil has constricted it remains small
for an abnormally long time (tonic pupil). The
presence of diminished reflexes make this
diagnosis the most likely. Headache is not a
common part of the syndrome, but could be
due to problems with vision.

Argyll-Robertson pupils are small, fail to react
to light, constrict with near vision
(accommodation), and are usually bilateral.
The Argyll Robertson pupil has become a rare
diagnostic sign of neurosyphilis.

There are no additional features to suggest a
third cranial nerve palsy, and absence of
ptosis makes Horner's syndrome unlikely.

[ Q: 1669 ] MRCPass - Ophthalmology

A 45 year old woman visits her GP with a 12
month history of headaches. These are
intermittent and occur when she has
problems with her vision. The GP has noticed
that her right pupil is larger than the left. The
right eye has very slow reaction to light and
did not completely constrict. The rest of the
neurological examination is normal except

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[ Q: 1670 ] MRCPass - Psychiatry

A 35 year old patient has been taking
drugs for a psychiatric disorder. She is brought
in by a flatmate, having had an episode where
her eyes rolled back in the head and the
tongue protruded involuntarily.

Which might be the medication causing this?

1- Procyclidine

2- Olanzepine

3- Haloperidol

4- Diazepam

5- Levetiracetam

Answer & Comments

Answer: 3- Haloperidol

The patient has an oculogyric crisis. Oculogyric
Crisis usually occurs as a side effect of
neuroleptic drug treatment. It is one of the
acute dystonic reactions. It is the most
common of the ocular dystonic reactions
(which include blepharospasm, periorbital
twitches, and protracted staring episodes).

5- Predisposing mental illness

Answer & Comments

Answer: 3- Replaying a tramatic scene in his
mind

Post traumatic stress disorder is a delayed
and/or protracted response to an
exceptionally stressful event. Symptoms
include episodes of reliving the trauma,
avoidance behaviour, persistent numbness,
detachment from people.

[ Q: 1672 ] MRCPass - Psychiatry

A 30 year woman complains of chest
pains and abdominal pains. On presentation
to the hospital she is found to have numerous
crusted, linear lesions on her forearms. A
dermatology consultation was arranged, and a
skin biopsy subsequently turned out to be
normal.

What is the likely diagnosis?

1- Scleroderma

2- Hereditary haemorrhagic telangiectasia

Causes or triggering factors in oculogyric crisis
include: neuroleptics, benzodiazepines,

carbamazepine, chloroquine, cisplatin,
influenza vaccine, levodopa, lithium,
metoclopramide, nifedipine, tricyclics.

^ [ Q: 1671 ] MRCPass - Psychiatry

* A 40 year old man was working as a
soldier in a war 10 years ago and has
previously been tortured. He is having
nightmares and mood swings.

Which of the following features is most
suggestive of post traumatic stress disorder?

1- Onset usually about 3 months after the
event

2- More common in older men

3- Replaying a tramatic scene in his mind

4- Low incidence in Europe

3- Schizophrenia

4- Factitious disorder

5- Depression

Answer & Comments

Answer: 4- Factitious disorder

Dermatitis artefacta is a condition in which
skin lesions are solely produced or inflicted by
the patient's own actions. This usually occurs
as a result or manifestation of a psychological
problem. It could be a form of emotional
release in situations of distress or part of an
attention seeking behaviour.

In very rare cases there may be an underlying
attempt to secure an insurance claim. The
rash described is consistent with dermatitis
artifacta. The crusted lesions on forearms

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suggest artefact as this the commonest site of
the lesions.

^ [ Q: 1673 ] MRCPass - Psychiatry

n -

# A 35 year old homeless man
presents with tonic clonic seizures to the
hospital. He says that he is epileptic, but his
GP surgery and hospital has no record of this.
He also says he takes phenytoin but the
plasma levels were unmeasurable. He was
admitted for several days and further
investigations of CT and EEG were normal.

Whot is the diagnosis?

1- Anxiety disorder

2- Malingering

3- Hypochondriasis

4- Somatisation

5- Korsakoff's psychosis

Answer & Comments

Answer: 2- Malingering

There is a difference between malingering and
Munchausen's syndrome.

Malingering patients have a clear secondary
gain, whilst there is no convincing secondary
gain in Munchausen's syndrome (occasionally
said to be due to attention seeking
behaviour).

^ [ Q: 1674 ] MRCPass - Psychiatry

* A 55 year old man has suffered
bereavement of his family member 8 months
ago. He continues to be constantly tearful and
depressed.

Whot is the most appropriate management?

1- Give tricyclic antidepressants

2- Assess for clinical depression and suicide
risk

3- Assess for schizophrenia

4- Reassure that he will get over it

5- Sleeping tablets

Answer & Comments

Answer: 2- Assess for clinical depression and
suicide risk

Depression is relatively common among
patients with chronic illnesses but can also
occur following bereavement. A history to
identify symptoms of clinical depression is
important, as well as assessment of suicide
risk. Antidepressants can be prescribed once
the diagnosis is firm.

[ Q: 1675 ] MRCPass - Psychiatry

A 35 year old lady has been
depressed and is brought to the hospital by a
friend after slashing her wrists.

Which of the following is a predictor that she
may make a fatal suicide attempt?

1- Depressed relative

2- Personality disorder

3- Female sex

4- Younger age group

5- A boyfriend who does not care

Answer & Comments

Answer: 2- Personality disorder

The characteristics of patients who are likely
to have repeated or successful suicide
attempts are: male sex, age of 45 more, drugs,
alcohol, personality disorder, living alone
(divorced or widowed), criminal record,
previous history of psychiatric treatment,
lower social class and unemployment.

[ Q: 1676 ] MRCPass - Psychiatry

A 25 year old biology student is
referred by her GP with possible UTI and
confusion. However, she has no new urinary
symptoms. Her MTS score is 10 /10 but she
has difficulty answ ering questions directly.

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Her friend describes her as a very pleasant
character who is very sociable in the pub.
Recently, her friend said she had become
quite disinhibited and and said she was going
to become a millionaire as soon as she started
work. She did However get annoyed easily
when her friends questioned how she was
going to achieve this.

Whot is the diagnosis?

1- Korsakoff's psychosis

2- Hypomania

3- Anxiety disorder

4- Depressive psychosis

5- Somatisation

2- Carbamazepine

3- Haloperidol

4- Chlorpromazine

5- Thioridazine

Answer & Comments

Answer: 1- Diazepam

Oral or subcutaneous diazepam can be given
to the patient to reduce the agitation and
violence, as this is likely to be a form of
delirium. It is short acting, hence a longer
acting sedating agent such as haloperidol may
be necessary second line.

Answer & Comments

Answer: 2- Hypomania

Persistent mood elevation with occasional
irritability is typical of hypomania. There is
distinct period of persistently elevated,
expansive, or irritable mood, sometimes
lasting several days, that is clearly different
from the usual non depressed mood.

The clinical features of mania reflect a marked
elevation of mood, characterized by euphoria,
overactivity and disinhibition. Hypomania is
the mild form of mania. Hypomania lasts a
shorter time and is less severe, with no
psychotic features and less disability.
Hypomania can be distinguished from normal
happiness by its persistence, non-reactivity
(not provoked by good news and not affected
by bad new s) and social disability.

[ Q: 1677 ] MRCPass - Psychiatry

A 75 year old man with history of
stroke with residual right hemiparesis has
become acutely confused. He is agitated and
is trying to attack any nursing staff who are
looking after him.

What should be prescribed?

1- Diazepam

[ Q: 1678 ] MRCPass - Psychiatry

A 45 year old man has taken an
overdose of 25 diazepam tablets. He is
assessed by the psychiatrist for risk for future
suicide.

Which of the following indicates a high risk?
1- Overdose with alcohol

2- Overdose with easily obtainable drugs

3- Making plans before an overdose

4- Previous overdoses

5- Unemployed

Answer & Comments

Answer: 3- Making plans before an overdose

Suicide intent is stronger in patients who plan
for the suicide. The more specific the plan, the
more serious the intent, for example - a will,
or giving things away.

[ Q: 1679 ] MRCPass - Psychiatry

A 45 year old lady has been
depressed for about year. She has early
morning waking, anhedonia and difficulty
sleeping. A diagnosis of clinical depression is
made.

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Which of the following forms of therapy is
recommended?

1- Psychoanalysis

2- Family counselling

3- Transactional analysis

4- Cognitive behavioural therapy

5- Dynamic counselling

Answer & Comments

Answer: 4- Cognitive behavioural therapy

Cognitive behavioural therapy is likely to be
effective in moderate clinical depression.

[ Q: 1680 ] MRCPass - Psychiatry

A 30 year old woman is 28 weeks
pregnant. She is brought into hospital for
assessment of recurrent vomiting.

She mentions that she has eaten very little
over several weeks. Examination reveals
MMSE score of 23/30 and

temporal disorientation, but registration is
intact. Recall was very poor.

What diagnosis is likely?

1- Korsakoff's syndrome

2- Parietal lobe syndrome

3- Frontal lobe syndrome

4- Creutzfeldt jakob disease

5- Alzheimer's disease

Answer & Comments

Answer: 4- Creutzfeldt jakob disease

The clinical context would fit for thiamine
deficiency related to hyperemesis gravidarum,
leading to Wenicke's Encephalopathy (WE).
This can develop after just a few weeks of
vomiting.

Early intervention with thiamine replacement
is typically all that is needed to prevent this
complication.

[ Q: 1681 ] MRCPass - Psychiatry

A 70 year old woman has become
increasingly confused over the past few
months. She is commonly disorientated.

Which one of the following is the most likely
feature of Alzheimer's disease?

1- Depression

2- Paranoid delusion

3- Impaired short term memory

4- Diarrhea

5- Hallucinations

Answer & Comments

Answer: 3- Impaired short term memory

Alzheimer's disease is typified by short term
memory loss which is progressive.

There is also inability to formulate plans and
aphasia.

^ [ Q: 1682 ] MRCPass - Psychiatry

I iS -

* A 50 year old man is complaining of
strange experiences over the past year. The
patient hears his own thoughts being spoken
aloud and, as a consequence, other people are
able to hear his thoughts as well.

Which of the following would suggest a
psychotic disorder?

1- Derealisation

2- Hypnagogic hallucination

3- Left right disorientation

4- Thought broadcast

5- Depersonalisation

Women may present with the classic triad of
symptoms, visual distrubances, confusion and
muscular weakness.

Answer & Comments

Answer: 4- Thought broadcast

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Thought broadcast is an example of thought
alienation.

In thought broadcast, the patient's thoughts
are either felt to be heard by someone else, or
projected (in another media e.g. video or
written). This suggests a psychotic disorder.

Other forms of thought alienation are thought
withdrawal and thought insertion.
Depersonalisation (person feels unreal) and
derealisation (environment feels unreal) are
present not only in psychotic disorders, but
also anxiety states and depression.

muscle pain

multi-joint pain without sw elling redness
headaches of a new type
pattern severity
unrefreshing sleep

post-exertional malaise lasting more than 24
hours

Low dose antidepressants are used in
treatment of CFS, but suggested first line
therapy should include cognitive

[ Q: 1683 ] MRCPass - Psychiatry

A 20 year year old university student
presents persistent fatigue, myalgia. He has
poor concentration in classes and mentions
that he is less sociable because he tends to get
irritable easily. All this started after a flu like
illness 1 year ago. A diagnosis of chronic
fatigue syndrome is made.

What is the best first line management of this
patient?

1- Psychoanalysis

2- Cognitive behavioural therapy

3- Fluoxetine

4- Chlorpromazine

5- ECT

Answer & Comments

Answer: 2- Cognitive behavioural therapy
The criteria for chronic fatigue syndrome are :

1) severe chronic fatigue of six months longer
duration

2) Have four more of following symptoms:
substantial impairment in short-term memory
poor concentration

sore throat
tender lymph nodes

behavioural therapy.

[ Q: 1684 ] MRCPass - Psychiatry

A 30 year old patient has been found
wandering on the street.

The police brought the patient for assessment
for suspected delusions and paranoia. The
patient is aggressive and wants to leave
straightaway.

What does the Section 5(2) of the Mental
Health Act allow a physician to do if mental
illness is suspected?

1- Detain a patient for up to 24 hours from
A&E

2- Detain a patient for up to 48 hours from
A&E

3- Detain a patient for up to 72 hours from
A&E

4- Detain a patient for up to 48 hours if they
are already being nursed in hospital

5- Detain a patient for up to 72 hours if they
are already being nursed in hospital

Answer & Comments

Answer: 5- Detain a patient for up to 72 hours
if they are already being nursed in hospital

Section 5(2) of the Mental Health Act allows a
physician or surgeon to detain a patient for up
to 72 hours if they are already being nursed in

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hospital when they are suspected of, or have a
worsening mental illness.

[ Q: 1685 ] MRCPass - Psychiatry

A 66 year old man was found with
decreased consciousness. There were some
chlorpromazine, diazepam and amitriptyline
tablets in his pocket. He also was found with a
half empty bottle of whisky.

He had a temperature of 38.2°C, GCS was
13/15 on arrival to A+E. Blood pressure was
170/100 mmHg and there was marked muscle
rigidity but normal reflexes and downgoing
plantars.

Whot is the diagnosis?

1- Bipolar disorder

2- Epilepsy

3- Narcolepsy

4- Catatonic schizophrenia

5- Neuroleptic malignant syndrome

Answer & Comments

Answer: 5- Neuroleptic malignant syndrome

Neuroleptic Malignant Syndrome is
characterized by fever, muscular rigidity,
altered mental status, decreased conscious
level and autonomic dysfunction.

Although potent neuroleptics (eg, haloperidol,
fluphenazine) are more frequently associated
with NMS, all antipsychotic agents, typical or
atypical, may precipitate the syndrome. For
example, these agents are prochlorperazine,
promethazine , clozapine and risperidone .

^ [ Q: 1686 ] MRCPass - Psychiatry

* An 17 year old student is very

anxious about her A levels. She is feeling dizzy
and may vomit several times when the exams
come closer to date.

Which of the following is the best

manogement?

1- Fluoxetine

2- Amitriptyline

3- ECT

4- Counselling

5- Diazepam

Answer & Comments

Answer: 4- Counselling

There is little evidence of psychiatric illness,
the patient has marked anxiety related to a
stressful event and counselling should be a
useful coping mechanism.

[ Q: 1687 ] MRCPass - Psychiatry

A 60 year old patient has been on an
antipsychotic medication for a while. He
develops a festinant gait and tremors in his
hand.

Which of the following antipsychotic
medications might have this side effect?

1- Risperidone

2- Haloperidol

3- Olanzepine

4- Quetiapine

5- Clozapine

Answer & Comments

Answer: 2- Haloperidol

All of the above are newer generation
antipsychotics. Haloperidol and trifluoperazine
are examples of older generation
antipsychotics which have parkinsonian side
effects.

[ Q: 1688 ] MRCPass - Psychiatry

An elderly patient presents with
fluctuating episodes of confusion, attention
problems and visual hallucinations.

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There is also a history of falls. A diagnosis of
Lew y body dementia is suspected. In this
patient which type of drug should be avoided?

1- Beta blockers

2- Neuroleptics

3- SSRIs

4- Anticonvulsants

5- Benzodiazepines

Answer & Comments

Answer: 2- Neuroleptics

Among patients with Lewy body dementia,
classical neuroleptic drugs (eg haloperidol)
have a high risk of causing an extrapyramidal
syndrome and increase mortality. Most
experts recommend atypical neuroleptics such
as risperidone, olanzapine, or clozapine.

[ Q: 1689 ] MRCPass - Psychiatry

A 60 year man has drunk 5 pints of
beer a day for 20 years. He had no other
significant medical history and was not taking
any regular medications. He presents with
acute confusion and has an MTS score of 5/10
on admission.

Which of following suggests o diagnosis of
Korsakoff's psychosis?

1- Confabulation

[ Q: 1690 ] MRCPass - Psychiatry

A 27 year woman complained
breathlessness, chest pains and severe
abdominal pains. She has previously been
abused by a family member. In past 10 years
she had investigated for abdominal pains,
without any diagnoses.

What is the likely diagnosis?

1- Depression

2- Factitious disorder

3- Somatisation disorder

4- Anxiety disorder

5- Personality disorder

Answer & Comments

Answer: 3- Somatisation disorder

Four major somatoform disorders exist:
conversion disorder (also known as hysteria),
hypochondriasis, somatization disorder, and
somatoform pain disorder.

The list of symptoms includes:

PAIN SYMPTOMS (4 or more) in the head,
abdomen, back, joints, extremities, chest.

GASTROINTESTINAL SYMPTOMS (2 or more,
excluding pain) such as nausea, bloating,
vomiting, diarrhea, intolerance of several
foods.

2- Auditory hallucinations

3- Visual hallucinations

4- Long term memory loss

5- Seizures

Answer & Comments

Answer: 1- Confabulation

Korsakoff's psychosis is typically associated
with short term memory loss and then
confabulation by patient when he is unable to
accurately describe something.

SEXUAL SYMPTOMS (at least 1, excluding pain)
including indifference to sex, difficulties with
erection or ejaculation, irregular menses,
excessive menstrual bleeding.

PSEUDONEUROLOGICAL SYMPTOMS (at least
1) including impaired balance or coordination,
weak muscles, trouble swallowing, loss of
voice, retention of urine, hallucinations,
numbness , double vision, blindness, deafness,
seizures, amnesia or other dissociative
symptoms.

[ Q: 1691 ] MRCPass - Psychiatry

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A 23 year old woman has had rapid breathing
attacks for 2 years. She has associated tingling
in her fingers during these episodes which
typically last for 5 minutes. She remains aw
are of her surroundings during the episodes.

What is the most likely diagnosis?

1- Obsessive compulsive disorder

2- Panic attacks

3- Schizophrenia

4- Dysmorphophobia

5- Somatoform disorder

A 55 old woman is referred with symptoms of
lethargy. Medical investigations did not show
any positive results.

She has been diagnosed as having chronic
fatigue syndrome.

What treatment should be commenced?

1- Long rest

2- Graded exercise

3- Benzodiazepines

4- Neuroleptics

5- Selective serotonin reuptake inhibitors

Answer & Comments

Answer: 2- Panic attacks

Answer & Comments

Answer: 2- Graded exercise

The features of hyperventilation with
subsequent paresthesiae in the fingers are
typical of panic attacks.

[ Q: 1692 ] MRCPass - Psychiatry

A 50 year old man has been on
lithium for bipolar disorder. His psychiatrist
thinks that the dose of lithium may be too
high due to a certain symptom.

Which of the following symptoms are a
feature of lithium toxicity?

1- Abnormal eye movements

2- Abdominal pains

3- Breathlessness and ankle oedema

4- Tremor and ataxia

5- Hallucinations

Answer & Comments

Answer: 4- Tremor and ataxia

Common symptoms of lithium toxicity (can
occur at levels greater than 1.1 mmol/l) are
nausea and vomiting, diarrhoea,
disorientation, tremors and ataxia.

[ Q: 1693 ] MRCPass - Psychiatry

Graded exercise programmes and cognitive-
behavioural therapy are the only therapies
which have been shown to be beneficial in
chronic fatigue syndrome.

[ Q: 1694 ] MRCPass - Psychiatry

# A 50 year old lady is pacing around
the ward a lot and not able to sleep at night.
Examination of the woman's mental status
revealed labile mood and affect, loud and
pressured speech. She did not have any
delusional thoughts or hallucinations.

What is the diagnosis?

1- Schizophrenia

2- Personality disorder

3- Anxiety disorder

4- Mania

5- Clinical depression

Answer & Comments

Answer: 4- Mania

Pressure of speech and flight of ideas (quick
succession of thoughts) occurs in mania. In
addition, speech rhyming and clanging (words
chosen for sound and not meaning - I ate

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food, rude, stood) are also important
suggestive features.

[ Q: 1695 ] MRCPass - Psychiatry

A 45 year man was arrested
following abnormal behaviour in the streets.
He was brought to the hospital for assessment
because he was felt to have delusional
behaviour, but then had a grand mal seizure
during examination.

Whot medication might hove led to the
seizure?

1- Amphetamine

2- LSD

3- Barbiturate

4- Cocaine

5- Chlorpromazine

Answer & Comments

Answer: 3- Barbiturate

Barbiturate withdrawal in an habitual abuser a
well recognised cause of fits.

referred to the psychiatric outpatient
department with a two month history of
washing her hands and legs and complaining
that ants were craw ling over her skin and
biting her.

The patient also described the insects as
having wings, and craw ling in the bathroom.
She would spend much time in the bathroom,
at times repeatedly throwing water to wash
them away, at other times leaving water for
them and enjoying watching them drink. She
also reported hearing rats scurrying around
the house.

Her husband reports that he had never seen
any insects or rodents in the house. She had
recently become slow and socially withdrawn.

During further assessment , which of the
following is o good prognostic factor?

1- Negative symptoms

2- Single

3- Male

4- Good response to medication

5- Poorly socially adjusted

Benzodiazepine elevates the level of an
inhibitory neurotransmitter, GABA, therefore
it serves as a tranquilizer.

Commonly abused barbiturates include
amobarbital and pentobarbital.

Answer & Comments

Answer: 4- Good response to medication

The diagnosis is likely to be schizophrenia as
the patient has hallucinations and delusions.

These drugs depress the respiratory and
nervous system functions; and, because
abusers rapidly build up a tolerance to the
effects of the drug, fatal overdose or coma can
easily occur.

Symptoms of withdrawal syndrome appear
12-20 hours after the last dose. They include
anxiety, irritability, elevated heart and
respiration rate, muscle pains, tremors,
confusion, and seizures.

Negative symptoms (blunted affect, emotional
withdrawal, apatheticness, social withdrawal,
lack of spontaneity), male, single, poor social
adjustment and poor response to medication
are all poor prognostic factors in
schizophrenia.

[ Q: 1697 ] MRCPass - Psychiatry

A 50 year old man has been involved
in a car accident is admitted for assessment.

[ Q: 1696 ] MRCPass - Psychiatry
A 45 year old housewife was

Since then, he has had memory loss and
fatigue. He is told that he may have frontal
lobe damage.

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Which of the following might be associated
with frontal lobe damage?

1- Left right disorientation

2- Homonymous hemianopia

3- Dressing apraxia

4- Finger agnosia

5- Perseverance

Answer & Comments

Answer: 5- Perseverance

1- Perseveration

2- Weight loss

3- Anhedonia

4- Loss of libido

5- Early morning waking

Answer & Comments

Answer: 1- Perseveration

Perseveration occurs in schizophrenia and
frontal lobe brain damage. Weight loss,

One of the specific behavior deficits following
frontal lobe damage is attention disorder,
patients showing distractibility and poor
attention. They present with poor memory,
sometimes referred to as "forgetting to
remember." The thinking of patients with
frontal lobe injury tends to be concrete, and
they may show perseveration and stereotypy
of their responses. The perseveration, with
inability to sw itch from one line of thinking to
another, leads to difficulties with arithmetic
calculations, such as serial sevens or carryover
subtraction.

Other features of frontal lobe syndromes
include aphasia, reduced activity, particularly
a diminution of spontaneous activity, lack of
drive, inability to plan ahead, and lack of
concern.

[ Q: 1698 ] MRCPass - Psychiatry

A 60 year old lady has reports of
increasing social withdrawal, marked apathy
tow ards all activities, hypersomnia, poor
appetite, and decreased energy. Her family
noted that she had frequently been confusing
appointments where she had previously been
quite organized and punctual. Mental status
exam revealed a woman with depressed mood
and blunted affect, who displayed marked
slow ness of mentation and apathy.

Which of the following symptoms suggests
frontal lobe damage?

anhedonia, loss of libido and early morning
waking are biological features of depression.

Confusional states, dementia, behavioral and
mood disturbances, including irritability,
euphoria, or depression, are also encountered
in frontal lobe tumors / lesions.

[ Q: 1699 ] MRCPass - Psychiatry

A 65 year old man was admitted
unwell and has been diagnosed with a chest
infection. On the second day of admission, he
becomes acutely confused and threatens to
attack another patient.

Which medication should be used for
sedation?

1- Trazadone

2- Lorazepam

3- Haloperidol

4- Clozapine

5- Chlorpromazine

Answer & Comments

Answer: 3- Haloperidol

Haloperidol is longer acting than the
benzodiazepines, and is one of the better
options for sedation. In addition, caution
should be used in a patient with respiratory
problems due to the risk of respiratory
depression.

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[ Q: 1700 ] MRCPass - Psychiatry

A 45 year old woman has lost her
husband in a road traffic accident 8

years ago. She is unable to discuss the event
without experiencing intense sadness.

Which of the following is an abnormal grief
reaction?

1- Insomnia

2- Poor appetite

3- Thoughts of dying

4- Feelings of hopelessness, guilt and
worthlessness

5- Feelings lasting 6 months from the event

Answer & Comments

Answer: 4- Feelings of hopelessness, guilt and
worthlessness

Grief reaction causes symptoms of decrease in
appetite, weight loss, ruminations, troubled
sleep, distractability, thoughts about dying,
and impaired concentration.

Symptoms last for up to 6 months.

Feelings of hopelessness, guilt and
worthlessness may signify depression or
abnormal grief reaction. Abnormal grief
reactions when symptoms persist for years
after and the patient still grieves as if the
event was recent.

[ Q: 1701 ] MRCPass - Psychiatry

A 50 year old man has a constant
inclination to arrange all the books in his
house, then rearranging it because he is not
satisfied it is in the appropriate order. He has
insight into the problem but is unable to
control his actions.

What is the diagnosis?

1- Delusional behaviour

2- Obsessive compulsive disorder

3- Drug abuse

4- Anxiety disorder

5- Transient global amnesia

Answer & Comments

Answer: 2- Obsessive compulsive disorder

A ritual may reduce anxiety but the behaviour
is not classically anxiety driven. An insight into
the obsessive behaviour but an inability to
control it is typical of obsessive compulsive
disorder

[ Q: 1702 ] MRCPass - Psychiatry

A 25 year old secretary has a history
of depression for 2 years. She was brought
into casualty by her sister. For a week, she had
grandiose delusions, hyperexcitement,
pressure of speech and flight of ideas.

The most likely diagnosis is:

1- Somatization

2- Schizophrenia

3- Bipolar disorder

4- Schizoaffective disorder

5- Depressive psychosis

Answer & Comments

Answer: 3- Bipolar disorder

The features described would fit with mania,
and would be most likely in conjunction with
bipolar disorder.

[ Q: 1703 ] MRCPass - Psychiatry

A 40 year male presents to the
hospital with multiple episodes of visual
hallucinations which last several days. He is
also vague and is not aw are of much of the
activity around him. On examination, the
patient is tremulous.

Paranoid psychosis is diagnosed by the junior
doctor but the consultant disagrees after
seeing results of deranged liver function tests.

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What is the likely diagnosis?

1- Dementia

2- Paranoia

3- Bipolar disorder

4- Alcohol withdrawal

5- Drug overdose

Answer & Comments

Answer: 4- Alcohol withdrawal

There are hallucinations and also clouding of
consciousness. This is suggestive of delirium
tremens or alcohol withdrawal. Clouding of
consciousness does not occur in dementia. It
occurs when the patient is awake and
functioning, but has an incomplete or
distorted aw areness of the environment. It is
a higher level of aw areness than stupor, in
which the awake patient is unaw are and
unresponsive to the environment.

[ Q: 1704 ] MRCPass - Psychiatry

A 55 year old man had an episode
he cycled very hard home after stress
at work. He developed an episode of memory
loss during which he was able to hold a
conversation, but seemed to lose any memory
of what happened at work. 6 hours later he
was able to recall everything except the
episode of memory loss.

What is the likely diagnosis of this event?

1- Subarachnoid haemorrhage

2- Frontal lobe infarct

where

attack lasts for hours, sometimes a whole day.
In many cases (up to a third), TGA is preceded

physical or emotional stress, rushing around
and personal dramas. Sex has frequently been
implicated as well.

A person with TGA is disorientated, though
physically well. They can think and
communicate, but forget what time it is or
where they are - responding to something
intelligently but after about a minute
forgetting. Despite patchy memory loss about
the recent past, distant memories remain. The
underlying cause is proposed to be vascular
insufficiency to the memory areas
hippocampi.

[ Q: 1705 ] MRCPass - Psychiatry

A 55 year old lady has presented
with chronic knee pain and sw elling. She has
been examined by a rheumatologist, and
along with knee X rays, no pathology was
found. She mentions that she is unable to
work due to the pain in her knee but is not
sure why she gets knee pains despite multiple
visits to the doctor without a diagnosis.

What is the likely problem?

1- Anxiety disorder

2- Somatisation

3- Dysmorphophobia

4- Schizophrenia

5- Hypochondriasis

3- Transient global amnesia

4- Schizophrenia

5- Mania

Answer & Comments

Answer: 3- Transient global amnesia

Transient Global Amnesia or TGA is a sudden
failure of memory, affecting older adults. The

Answer & Comments

Answer: 2- Somatisation

Patients with hypochondriasis have a high rate
of psychiatric comorbidity.

The core feature of hypochondriasis is not
preoccupation with symptoms themselves,
but rather the fear or idea of having a serious
disease. The fear or idea is based on the

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misinterpretation of bodily signs and
sensations as evidence of disease.

Somatization disorder is marked by multiple
medically unexplained physical, or somatic,
symptoms. The somatic complaints must be
serious enough to interfere significantly with a
person's ability to perform important
activities, such as work or family, or lead the
person experiencing the symptoms to seek
medical treatment. Dysmorphophobia is a
psychiatric condition, also termed body
dysmorphic disorder. It is characterised by a
fixation on an imaginary flaw in the physical
appearance (e.g. hair or acne).

[ Q: 1706 ] MRCPass - Psychiatry

A 35 year patient has recently
received a new drug for schizophrenia. He
presented 3 weeks later a with a fever and felt
lethargic. His investigations show : Hb 11.5
g/dl, WCC 2.3 xl0 9 /l, Platelets 122 xl0 9 /l.

Which is likely to be the drug which was
commenced?

1- Carbamazepine

2- Haloperidol

3- Clozapine

4- Chlorpromazine

5- Thioridazine

Answer & Comments

Answer: 3- Clozapine

Clozapine induced agranulocytosis occurs in
about 1% to 10% of patient who take
clozapine. Patients who have experienced
agranulocytosis with prior treatment of
clozapine should not receive clozapine again.

next year complained of breathlessness. She
has not worked since the symptoms started.

She does not have insight that despite
multiple negative investigations her symptoms
may not be organic. She has had a second
opinion and continues to seek a different
opinion.

What is the diagnosis?

1- Somatisation disorder

2- Conversion disorder

3- Hypochondriacal disorder

4- Delusional disorder

5- Depression

Answer & Comments

Answer: 1- Somatisation disorder

The constant change in symptoms with
negative clinical investigation results suggests
somatisation. In hypochondriacal disorder the
patients concentrate more on a disease e.g.
diabetes or migraines, rather than the
symptoms.

[ Q: 1708 ] MRCPass - Psychiatry

A 30 year old patient has admitted to
having suicide intention to the medical staff
on the wards.

Which one of the following is a worrying
feature?

1- Number of tablets overdosed

2- Female sex

3- Age 30

4- Writing a suicide note

5- Absence of family history

Answer & Comments

Answer: 4- Writing a suicide note

A 50 year old lady has had abdominal pains for
2 years, headaches for a year and then the

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The act of writing a suicide notes indicates
planning and intention of suicide (as opposed
to impulsive overdose).

Young and old ages, male sex, family history
and planning are features of increased risk in
deliberate self harm.

[ Q: 1709 ] MRCPass - Psychiatry
A 65 year old man is assessed for

cognitive impairment.

His wife mentions that his memory has not
been as good lately. He has been leaving the
front door open and the cooker on
occasionally.

Which of the following features suggests
frontal lobe dysfunction?

1- Impaired longterm recall

2- Perserveration

3- Sensory ataxia

4- Finger agnosia

5- Astereognosis

Answer & Comments

Answer: 2- Perserveration

Perseveration is the act of persisting;
continuing or repeating behavior. This can be
associated with difficulties in planning or
executing action. Frontal lobe changes also
include personality change, disinhibition,
euphoria and apathy.

4^ [ Q: 1710 ] MRCPass - Psychiatry

# A 50 year old woman has been
taking lithium for more than 10 years for
bipolar disorder.

Which of the following is a known side effect?

1- Polyuria

2- Optic atrophy

3- Weight loss

4- Raynaud's syndrome

5- Telangiectasia

Answer & Comments

Answer: 1- Polyuria

Polyuria and polydipsia, fine tremor of the
hands, weight gain, nausea and
hypothyroidism are side effects of lithium.

[ Q: 1711 ] MRCPass - Psychiatry

A 55 year old woman with memory
loss is considered for a diagnosis of
Alzheimer's disese by the psychogeriatrician.

Which of these is typical of early Alzheimer's
disease?

1- Impaired short term memory

2- Urinary incontinence

3- Seizures

4- Cerebellar signs

5- Auditory hallucinations

Answer & Comments

Answer: 1- Impaired short term memory

Alzheimer's disease is typified early in disease
by short term memory loss.

[ Q: 1712 ] MRCPass - Psychiatry

A 21 year old has come to hospital
complaining of nausea. She also complains of
frequent episodes of restlessness, inability to
sleep and also paresthesiae in her hands.
There is no relevant past medical history.

What is the diagnosis?

1- Somatisation

2- Conversion disorder

3- Personality disorder

4- Anxiety disorder

5- Post traumatic stress disorder

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Answer & Comments

Answer: 4- Anxiety disorder

The condition starts in early adult life, and is
associated with depression.

Symptoms typically associated with anxiety
are :

restlessness or feeling keyed up or on edge

paresthesiae

being easily fatigued

difficulty concentrating or mind going blank

irritability

muscle tension

sleep disturbance

[ Q: 1713 ] MRCPass - Psychiatry

A 35 year old woman contamination
obsessions and washing compulsions in the
preceding one month.

Preoccupied with thoughts of contamination,
she had started spending the majority of time
washing herself or cleaning various household
items.

She described these thoughts as being her
own and recognised them to be "irrational",
but she could not resist them.

[ Q: 1714 ] MRCPass - Psychiatry

A 55 year old lady is constantly tired
and is off work frequently despite previously
having been very conscientious at work. She
complains of mild headaches and myalgia. Her
sleep pattern was irregular and she found it
difficult to sleep at night. She mentions that
she gets tired doing very little. Neurological
examination is unremarkable.

What is the diagnosis?

1- Psychotic depression

2- Anorexia nervosa

3- Anxiety disorder

4- Chronic fatigue syndrome

5- Schizophrenia

Answer & Comments

Answer: 4- Chronic fatigue syndrome

Chronic fatigue syndrome is defined as
unexplained fatigue of at least six months'
duration. 4 of the following symptoms satisfy
the criteria:

Which one of following is true regarding
obsessional neurosis?

1- It starts in the elderly

2- There is no risk depression

3- There is good insight

4- The patients tend to be violent

5- Low intelligence is typically associated

the Joint pain

Ineffective sleep
Tender lymph nodes
Myalgia
Headache

Subjective memory impairment

Answer & Comments

Answer: 3- There is good insight

Obsessional neuroses causes rituals or
thoughts. Although some of the thoughts may
involve trying to hurt others, there is good
insight and patients are not typically violent.

Postexertional lethargy

(

• ( J

[ Q: 1715 ] MRCPass - Psychiatry

A 40 year old accountant has bipolar
disorder. He has recently become very
talkative and is unable to concentrate at work.
Hypomania is diagnosed.

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What is the recommended treatment?

1- ECT

2- Lithium

3- Olanzepine

4- Procyclidine

5- Fluoxetine

Answer & Comments

Answer: 3- Olanzepine

Lithium is used for prophylaxis in bipolar
disorder. Olanzepine or benzodiazepines are
more effective during episodes of hypomania.

[ Q: 1717 ] MRCPass - Psychiatry

A 55 year old man presents with a 10
day history of confusion. His friend
mentions that he drinks 15 units of alcohol a
day.

Which of the following strongly suggests a
diagnosis of Korsakoff's psychosis?

1- Absence seizures

2- Delusional beliefs

3- Poor long term memory

4- Inventing recent events

5- Auditory hallucinations

[ Q: 1716 ] MRCPass - Psychiatry

A 40 year old patient is assessed for
periods of breathlessness. Although she is a
smoker and has early bronchitis. She describes
uncontrollable episodes where she has
intense fear that she will die. During these

episodes she shakes and hyperventilates.
What is the diagnosis?

1- Panic disorder

2- Psychotic depression

3- Post traumatic stress disorder

4- Somatisation

5- Obsessional neurosis

Answer & Comments

Answer: 1- Panic disorder

One of the characteristic features of panic
disorder is the fear that something drastic is
going to happen during an attack, e.g.
impending doom. The episode usually lasts for
several minutes, and the patient may react
with fear or try to escape the situation. A
permanent feeling of nervousness suggests
generalised anxiety disorder rather than panic
disorder.

Answer & Comments

Answer: 4- Inventing recent events

Korsakoff's is typified by associated short term
memory loss and confabulation (inventing
recent events).

[ Q: 1718 ] MRCPass - Psychiatry

A 66 year old man has become more
forgetful over the last 12 months.

His wife complains that he does not
remember his friends' names and on several
occasions has gone for a walk and not found
his way back. He is also unsteady on his feet.
On examination he has a mask like face and
cogw heel rigidity of his upper limbs.

The most likely diagnosis is:

1- CJD

2- NvCJD

3- Vascular dementia

4- Lewy body dementia

5- Alzheimer's disease

Answer & Comments

Answer: 4- Lewy body dementia

Lew y body dementia is characterised by
fluctuating cognition, visual hallucinations,

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parkinsonism, falls, transient loss of
consciousness and delusions

Answer & Comments

Answer: 5- Obsssive compulsive disorder

[ Q: 1719 ] MRCPass - Psychiatry

A 23 year old man who suffers from
schizophrenia has been on chlorpromazine. He
complains of gynaecomastia and
galactorrhoea.

In this patient , chlorpromazine could be
changed to:

1- Haloperidol

2- Quetiapine

3- Thioridazine

4- Sulpiride

5- Risperidone

Answer & Comments

Answer: 2- Quetiapine

Classical antipsychotics increase plasma
prolactin concentrations by their blocking
action on dopamine receptors in the
tuberofundibular pathw ay. They can cause
gynaecomastia and galactorrhoea and
menstrual disturbances. A change to an
atypical agent such as quetiapine or
olanzapine should minimise this effect.

The predominant feature of obsessive
compulsive disorder is a ritual which is
unreasonable, but essentially unstoppable.

[ Q: 1721 ] MRCPass - Psychiatry

A 50 year old man has recently been
treated with amitriptyline. His brother brings
him to the hospital following an episode
where he went to the street telling passersby
that he is going become the King of the
country and conquer the world with battles.

On examination, he was euphoric and irritable
mood, mild grandiosity, decreased need for
sleep, rapid and pressured speech.

What is the likely diagnosis?

1- Schizophrenia

2- Somatization disorder

3- Depressive psychosis

4- Hypomania

5- Anxiety disorder

Answer & Comments

Answer: 4- Hypomania

[ Q: 1720 ] MRCPass - Psychiatry

A 25 year old woman constantly
washes her hands because of a fear of
infection, even at times when she has not
touched anything.

What is the diagnosis?

1- Personality disorder

2- Chronic fatigue syndrome

3- Depression

4- Schizophrenia

5- Obsssive compulsive disorder

The features of disinhibition suggest
hypomania. The diagnosis is bipolar disorder.
A mild to moderate level of mania is called
hypomania. Hypomania may feel good to the
person who experiences it and may even be
associated with good functioning.

[ Q: 1722 ] MRCPass - Psychiatry

A 30 year old patient presents with
headache and numbness in her right arm. CT
of the head is normal. There were no
organisms seen in the CSF and protein is
normal.

Upon further enquiry there is a history of
sexual abuse.

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What is the probable diagnosis?

1- Clinical depression

2- Obsessive compulsive disorder

3- Conversion disorder

4- Anxiety disorder

5- Acute psychosis

Answer & Comments

Answer: 3- Conversion disorder

Significant stress or emotional conflicts (such
as sexual abuse) are the most likely
predisposing causes for conversion disorder.

[ Q: 1723 ] MRCPass - Psychiatry

A 65 year old man has had clinical
depression diagnosed for 10 years. He initially
responded to fluoxetine, but now is getting
more episodes of depression and is suicidal.

What is the next best management?

1- Change to paroxetine

2- Change to amitriptyline

3- ECT

4- Allow natural progression

5- Dementia tests

Answer & Comments

Answer: 3- ECT

ECT is indicated in patients who have
responded to antidepressant medications
before, but may not be responding now .

Severe depression (melancholia) is the most
frequent indication for ECT. Patients with this
illness experience sadness and despair, have
difficulty concentrating, lose appetite and
weight, sleep poorly, blame themselves, are
unable to enjoy life, and often think of suicide.
Mania and schizophrenia are other illnesses
that can be helped by ECT.

[ Q: 1724 ] MRCPass - Psychiatry

Clozapine is an atypical antipsychotic
drug that appears to have fewer
problems with adverse effects than older
antipsychotics.

The relative safety of clozapine is due to:

1- Low affinity for 5HT receptors

2- Decrease in prolactin levels

3- No effect on haematopoiesis

4- Low affinity for dopamine D2 receptors

5- Causes sinus tachycardia

Answer & Comments

Answer: 4- Low affinity for dopamine D2
receptors

Clozapine appears to have fewer
extrapyramidal adverse effects than older
antipsychotics due to its relatively low affinity
for D2 dopamine receptors.

Unlike older antipsychotics, clozapine has
relatively high affinity for 5HT receptors, and
also has little effect on prolactin levels.

Myocarditis and cardiomyopathy have been
reported with atypical antipsychotics, and
persistent tachycardia is an early warning sign.
Agranulocytosis is a well-recognized
complication of clozapine, and patients should
be supervised under the Clozaril Patient
Monitoring Service.

[ Q: 1725 ] MRCPass - Psychiatry

A patient with parkinson's disease
has recently been commenced on an
antipsychotic drug. He has worsening of
rigidity and tremors.

Which of the following is the best
antipsychotic drug to prevent such features?

1- Risperidone

2- Chlorpromazine

3- Thioridazine

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4- Haloperidol

5- Clozapine

Answer & Comments

Answer: 5- Clozapine

Clozapine and quetiapine are newer, atypical
antipsychotic drug which does not have
parkinsonian side effects as bad as the older
generation drugs. This is due to less dopamine
receptor antagonism.

[ Q: 1726 ] MRCPass - Psychiatry

A 40 year old lady is brought to
hospital by a friend having taken 30 tablets of
fluoxetine 20mg all at one time. She was
attempting to commit suicide.

Which of the following would be consistent
with this when she is assessed?

1- Heart rate of 100 beats per minute

2- Miosis

3- Respiratory rate of 20

4- QRS duration of 150 ms

5- Seizures

Answer & Comments

Answer: 1- Heart rate of 100 beats per minute

With fluoxetine overdose, most patients are
asymptomatic. About 20% of patients may
feel drow sy and have a sinus tachycardia.

[ Q: 1727 ] MRCPass - Psychiatry

A 20 year lady referred a year's
history of oligomenorrhea. She is currently in
university and has reports of poor progress
with her work. On examination, she was found
to have lanugo hair.

Whot is the diagnosis?

1- Polycystic ovary syndrome

2- Anorexia nervosa

3- Bulimia

4- Anxiety disorder

5- Depression

Answer & Comments

Answer: 2- Anorexia nervosa

Lanugo hair is a fine hair that develops on the
face, back, or arms and legs. This occurs in
anorexia nervosa.

[ Q: 1728 ] MRCPass - Psychiatry

A 50 year old man has a history of
alcohol excess, presents with a 2 week history
of confusion.

Which of the following suggests a diagnosis of
Korsakoff's psychosis?

1- Visual hallucinations

2- Epileptic seizures

3- Impaired longterm memory

4- Delusional beliefs

5- Confabulating events

Answer & Comments

Answer: 5- Confabulating events

The main features of Korsakoff's psychosis is
short term memory loss and subsequent
compensatory confabulation by patient. Other
symptoms may include delirium, anxiety,
depression, confusion, delusions and
insomnia. The treatment is with intravenous
thiamine.

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[ Q: 1729 ] MRCPass - Statistics

A group of 100 patients were
involved in a study of clubbing and
endocarditis. There were 8 patients with SBE
and clubbing, 2 patients with SBE without
clubbing. There were 90 patients without SBE
and 5 of these patients had clubbing.

Which of the following is true?

1- Positive predictive value = 8/(8+2)

2- Negative predictive value = 85/(85+2)

3- Sensitivity = 8/(8+5)

4- Sensitivity = 8/(8+85)

5- Specificity = 85/(85+2)

Answer & Comments

Answer: 2- Negative predictive value =
85/(85+2)

This is a good exercise for calculating
sensitivity etc. A contingency table for this
should be drawn out.

SBE

No SBE

Clubbing

No Clubbing

The total of all patients is 100. PPV = 8/(8+5).
NPV = 85/(85+2). Sensitivity = 8/(8+2).
Specificity = 85/(85+5).

Predictive Value Positive

-►

Disease

Sensitivity

Yes

No |

Pos

Test

Neg

Specificity

group was 5% compared to a incidence of 8%
in untreated group (p<0.001).

What is the relative risk reduction ?

1- 5%

2 - 8 %

3- 3%

4- 3/8%

5- 5/8%

Answer & Comments

Answer: 4- 3/8%

The drug reduced the risk from 8% to 5%,
hence the relative risk reduction is the
difference divided by the original risk ie 3/8%.

[ Q: 1731 ] MRCPass - Statistics

In a trial of an antiplatelet therapy in
secondary prevention of stroke, the drug was
shown to reduce mortality from stroke, from
8% to 4% over 10 years.

What is the number needed to treat to prevent
a death over 10 years?

1- 4

2- 5

3- 10

4- 25

5- 100

Answer & Comments

Answer: 4- 25

< -

Predictive Value Negative

[ Q: 1730 ] MRCPass - Statistics

A study has been performed on
preventing lung cancer with a drug Y in a
population who smoked. The results of the
study showed that over a 5 year period the
incidence of lung cancer in the drug Y treated

The drug reduced the risk of death post stroke
by 4% over 10 years. Therefore if 100 people
were treated we could expect the prevention
of 4 deaths.

100/Absolute risk reduction = Number needed to treat

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[ Q: 1732 ] MRCPass - Statistics

A study examines patients with bow
el carcinoma. The mortality rate of those
given drug R is 7%, compared with 10% in
those not given drug R.

What conclusion can be drawn?

1- The relative risk of death when given drug R
is 1.5

2- The relative risk of death when given drug R
is 7/10

3- The number needed to treat to prevent one
death is 3

4- The number needed to treat to prevent one
death is 10

5- The absolute risk reduction is 3%

Answer & Comments

Answer: 5- The absolute risk reduction is 3%

The absolute risk reduction is 10 - 7 = 3%. The
relative risk reduction is 3/10. The number
needed to treat is 100/absolute risk reduction
which is 33 in this case.

100/Absolute risk reduction = Number needed to treat

[ Q: 1733 ] MRCPass - Statistics

A surveillance study of a new
medication for treatment of cholesterol has
been carried out on 1,000 subjects who had
completed clinical trials in the postmarketing
phase.

Which of the following shows information
generated from this study?

1- Cost-effectiveness

2- Efficacy

3- Cost benefit analysis

4- Effectiveness

5- Adverse events

Answer & Comments

Answer: 5- Adverse events

The postmarketing phase is phase IV. In this
phase, the potential side effects in the large
population is assessed under everyday
conditions. Drug potency is usually assessed in
phase II, and efficacy assessed in phase III.

[ Q: 1734 ] MRCPass - Statistics

A treatment has been shown to be
of benefit in treating Crohn's disease following
a phase II study in patients.

However there were concerns regarding
deranged liver function from this treatment in
animal studies.

What study should be conducted ?

1- Case controlled study

2- Randomised double blind placebo study

3- Metanalysis

4- Sequential trial

5- Phase I study

Answer & Comments

Answer: 2- Randomised double blind placebo
study

The study has already been performed to
phase II and hence

should have been shown to be safe in phase I.
The next step should be a randomised double
blind study to determine whether there would
be benefit, and also whether the side effects
are significant.

[ Q: 1735 ] MRCPass - Statistics

The number needed to treat (NNT) is
defined as:

1- 0.5 divided by absolute risk reduction

2- 0.5 divided by relative risk reduction

3- 100 divided by absolute risk reduction

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4- 100 divided by relative risk reduction

5- The percentage of difference x patient

Answer & Comments

Answer: 3- 100 divided by absolute risk
reduction

NNT can be calculated by 100 divided by the
number for absolute risk reduction, or 1
divided by the percentage of absolute risk
reduction.

100/Absolute risk reduction = Number needed to treat

[ Q: 1737 ] MRCPass - Statistics

A group of investigators studied
dizziness as a symptom of CVA. Out of 100
patients, there were 20 patients with
dizziness. 10 of these patients had CVA. There
were a further 5 patients who did not have
dizziness, who had CVA.

What is the pretest probability?

1 - 10/20

2- 5/20

3- 10/100

4- 15/100

5- 20/100

[ Q: 1736 ] MRCPass - Statistics
Which of the following defines

variance?

1- 2x standard deviation

2- Square of standard deviation

3- Square root of standard deviation

4- Half of standard deviation

Answer & Comments

Answer: 4-15/100

Pretest Probability is defined as the
probability of the target disorder before a
diagnostic test result is known. This is actually
the same as the disease prevalence, in this eg
CVA prevalence. Hence (10 + 5)/100 = 15/100.

5- Standard deviation divided by number in
the population

Answer & Comments

Answer: 2- Square of standard deviation

Variance is the square of standard deviation.
Standard deviation is the square root of
variance.

R * = I(x-x) 2

Variance

s ='V I< r 1

Standard Deviation

^ [ Q: 1738 ] MRCPass - Statistics

fl 1 - 1 -

The mean Hb value for a group of
150 patients is 15 g/dl. The standard deviation
is 2 g/dl.

Which one of these conclusions is correct?

1- 68% of patients have a Hb between 13 and
17 g/dl

2- 95% of patients have a Hb between 13 and
17 g/dl

3- 99% of patients have a Hb between 13 and
17 g/dl

4- Variance is 2

5- Variance is 1

Answer & Comments

Answer: 1- 68% of patients have a Hb between
13 and 17 g/dl

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68% of patients fall within 1 standard
deviation, in this case, 2 less and more than
15. 95% of patients would have a Hb between
11 and 19.

Standard deviation is the square root of
variance. Hence variance is 4.

r 2 = I(X-X) E

Variance

s -Vlp 1

Standard Deviation

regarding standard error of the mean (SEM)?

1- SEM estimates how different a median is
compared to the population mean

2- 75% confidence limits for a mean are the
mean +/-1.96 SEM

3- SEM would be halved if we doubled the
sample size

4- SEM would be halved if we quadrupled the
sample size

5- SEM increases as standard deviation
decreases

Answer & Comments

Answer: 4- SEM would be halved if we

quadrupled the sample size

[ Q: 1739 ] MRCPass - Statistics

A letter published in a journal
suggests that an established antipsychotic
drug may cause photosensitivity. The
manufacturer wishes set up a study to
determine rapidly and efficiently whether this
is true.

Which one of the following studies is most
appropriate?

1- Case control study

2- Dose ranging study

3- Double blind, randomized, placebo
controlled study

4- Meta-analysis

5- Sequential trial

Answer & Comments

Answer: 4- Meta-analysis

An established drug should have many trials
published on data. Meta-analysis incorporates
the data in order to identify effects which
some trials may be too small to detect.

[ Q: 1740 ] MRCPass - Statistics
Which one of the following is correct

Standard error of the mean estimates how
close a study mean is compared to the
population mean.

The formula for Standard Error of the Mean =
Std Dev/ Square Root of Sample Size. Hence,
the SEM would be halved if the sample size
were quadrupled.

95% of observations lie 1.96 (or nearest
estimate 2) standard deviations aw ay from
the mean. SEM increases as the standard
deviation increases.

Standard error (sent):

The standard error of the mean is
designated as: om It is the standard
deviation of the sampling distribution of
the mean The formula for the standard
error of the mean is:

where a is the standard deviation of the
original distribution and N is the sample
size (the number of scores that each mean
is based on)

[ Q: 1741 ] MRCPass - Statistics

Which of these is an example of a
nonparametric test?

1- Chi square

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2- Students t test

What is the number needed to treat over 10

3- Kaplan Meier analysis

years to prevent 1 death ?

4- Wilcoxon rank test

1-5

5- Correlation coefficient

2- 10

3- 15

Answer & Comments

4- 20

Answer: 4- Wilcoxon rank test

5-25

The nonparametric tests can be used when
distribution is not normal (skewed). The
Wilcoxon rank sum test and Mann U Whitney
tests are good examples of nonparametric
tests. Other examples are the Kruskal-Wallis
(KW) test and Friedman's test.

[ Q: 1742 ] MRCPass - Statistics

A publication assesses a tumour
marker used to test for ovarian cancer.

Which of the following would demonstrate the
number of coses of ovarian cancer correctly
identified by this new test , out of all the
ovarian cancer cases?

1- Sensitivity

2- Specificity

3- Positive predictive value

4- Negative predictive value

5- Accuracy

Answer & Comments

Answer: 1- Sensitivity

Answer & Comments

Answer: 4- 20

NNT is defined as number needed to treat to
prevent 1 death. The way to work this out is
100 /(15 -10) = 20.

100/Absolute risk reduction = Number needed to treat

^ [ Q: 1744 ] MRCPass - Statistics

n -

* A study is conducted measuring
body weight and risk of progession tow ards
hypertension.

Which of following best statistical test to
evaluate results?

1- Student's paired t test

2- Chi squared test

3- Student's unpaired t test

4- Coefficient of linear regression

5- Log rank test

The sensitivity assess how many pickups there
are with the test, hence the number of cases
correctly identified out of all the cases.

^ [ Q: 1743 ] MRCPass - Statistics

/ l — UJ - - WL -

* A study compared carotid
endarterectomy with medical therapy for
stroke prevention over 10 years. There were
15% of patients developing in the medical
group, and 10% in the carotid endarterectomy
group developing a stroke.

Answer & Comments

Answer: 4- Coefficient of linear regression

In such a study, a plot of weight against
hypertension would allow regression analysis.

A coefficient can be obtained to
demonstrated how closely associated they are
(the closer to a value of 1, the higher the
coreelation).

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[ Q: 1745 ] MRCPass - Statistics

The sensitivity of a new blood test
(Blood Test X) for heart failure has been
assessed in heart failure. The test results were
compared with echocardiography as a gold
standard for the diagnosis of heart failure. The
following are the results:

Heart Failure

No heart

failure

X positive

\ 30

10 \

X negative

45 i

What is the sensitivity of blood test X?

1- 5/30

2- 10/35

3- 30/35

4- 5/45

5- 30/45

There a 10% risk of myocardial infarction in
the group receiving the drug and 20% risk of
Ml in the placebo group.

What number of patients are required to
prevent one myocardial infarction?

1- 1

2- 5

3- 10

4- 20

5- 100

Answer & Comments

Answer: 3-10

The absolute risk reduction is 10% and the
relative risk reduction is 0.5.

The number needed to treat is 100 divided by
the absolute risk reduction.

Answer & Comments

Answer: 3- 30/35

The sensitivity is the number of positive pick
ups out of all those who had the condition.
Taking into account patients with heart
failure, 30 patients had Blood test X positive
and 5 patients had Blood test X negative.
Hence sensitivity (expressed in %) of Blood
Test X is 30/35.

Predictive Value Positive

-►

Disease

Sensitivity

Yes

No |

Pos

Test

Neg

Specificity

* -

Predictive Value Negative

[ Q: 1746 ] MRCPass - Statistics

A randomised double blind
controlled study of a blood pressure low ering
drug assessed its effect on myocardial
infarction. The follow up period was 10 years.

This would be 100/10 which is 10.

^ [ Q: 1747 ] MRCPass - Statistics

A -

# A set of data has been collected for
treatment for breast cancer as follows :

Survived

Not Survived

With Drug

Without Drug

is ~1

Which is the best form of analysis?

1- Students' t test

2- Chi square test

3- Pearson's correlation

4- Survival analysis

5- Kendall's test

Answer & Comments

Answer: 2- Chi square test

This is a 2x2 contingency table. A statistics
calculator can be used to obtain a p value with
the chi square test to determine if the
treatment has made a significant difference.

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[ Q: 1748 ] MRCPass - Statistics

A new blood test for pulmonary
embolism has a sensitivity of 99% and a
specificity of 20%. It has a positive predictive
value of 30% and a negative predictive value
of 40%.

A test with these characteristics would be
inappropriate in which conditions?

1- Screening many patients to identify for
CTPA

2- Screening in A+E, to admit all patients who
are positive for blood test

3- Screening in A+E and discharging all
patients who are negative

4- Screening in circumstances which
symptoms are suggestive but confirming
with a VQscan

5- Telling patients with a positive blood test
they may have PE but it is not a definitive
test

Answer & Comments

Answer: 3- Screening in A+E and discharging
all patients who are negative

The test has a high pick up rate or sensitivity,
but is not specific enough to exclude PE.
Hence patients who have a positive test
should have a second test such as VQ or CTPA
to confirm the diagnosis. PE cannot be safely
excluded unless the negative predictive value
is high.

[ Q: 1749 ] MRCPass - Statistics

A group of Turner's syndrome
patients have their heights measured in a
study.

Which of the following gives a good estimate
of the spread of heights?

1- Standard deviation

2- Mean

3- Mode

4- Median

5- Standard error of mean

Answer & Comments

Answer: 1- Standard deviation

The standard deviation would give the best
estimate of a spread of a measurement about
the mean, in this case, height.

[ Q: 1750 ] MRCPass - Statistics

In a study for a new drug, a
researcher wants to compare the
concentration of the drug at rest, and after
exercise in several subjects.

Which of the following tests is appropriate to
assess for a difference?

1- Pearson's correlation coefficient

2- Paired t test

3- Chi square test

4- Wilcoxon rank test

5- Unpaired t test

Answer & Comments

Answer: 2- Paired t test

The drug is assessed with the same volunteers
but with different conditions. This means that
a paired t test can be used.

[ Q: 1751 ] MRCPass - Statistics

A nationw ide cross-sectional survey
was conducted to compare the prevalence of
asthma symptoms among high school
students who have smoked compared to
those who have not smoked.

Which one of the following tests is best used
to compare its prevalence?

1- Mann Whitney test

2- Logistic regression analysis

3- Spearmann's correlation

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4- Chi square test

Answer & Comments

5- Kaplan Meier curve

Answer: 2- Negative predictive value

Answer & Comments

Answer: 4- Chi square test

The negative predictive value tells us the
proportion of individuals who test negative
who do not have a target condition.

In order to compare the prevalence in two
groups, the chi square test is most
appropriate.

[ Q: 1752 ] MRCPass - Statistics

A new genetic test for Marfan's
syndrome has recently been tested.

Which of the following can test for the number
of patients who would be identified by the
test?

1- Positive predictive value

2- Negative predictive value

3- Variation

4- Sensitivity

5- Specificity

[ Q: 1754 ] MRCPass - Statistics

The frequency of attendance of a
100 medical students at lectures were
recorded by an observer over a 3 month
period. The students were then assessed at
the end with a multiple choice exam with a
test score marked out of a hundred.

Which of these statistical methods is best used
to analyse the effectiveness of frequency of
attendance on higher test scores?

1- Mann-Whitney test

2- Spearmann correlation

3- Chi square test

4- Fisher's exact test

5- Student's t test

Answer & Comments

Answer: 4- Sensitivity

The sensitivity of a test is the proportion of
people with the disease who have a positive
test result. The higher the sensitivity, the
greater the detection rate.

Answer & Comments

Answer: 2- Spearmann correlation

Spearmann's correlation is the best method to
determine two variables which do not follow a
normal distribution.

[ Q: 1753 ] MRCPass - Statistics

A new diagnostic blood test for
pulmonary embolus has been described. Out
of all patients tested negative, which
parameter measures the true numbers of
patient who do not have pulmonary embolus?

1- Positive predictive value

2- Negative predictive value

3- Sensitivity

4- Specificity

5- Odds ratio

[ Q: 1755 ] MRCPass - Statistics

A randomised, double blind, placebo
controlled trial of an asthma drug has been
performed. 1000 subjects are treated with
active drug and 1000 are treated with
placebo. They are followed up over a five year
period. 200 individuals in placebo group 150
in treatment group had hospitalisation due to
asthma.

What is the annual percentage relative risk
reduction of asthma hospitalisation in the
treatment group as compared to the placebo
group?

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1- 2.5%

2- 5%

3- 10%

4- 25%

5- 50%

Answer & Comments

Answer: 2- 5%

The absolute risk reduction is 50 and the
relative risk reduction is 50/200, which is 25%.
However, the annaul percentage is required,
hence divided by 5, it is 5%.

[ Q: 1756 ] MRCPass - Statistics

In a survey of 100 patients, 30 had
ascites of which 25 had alcoholic cirrhosis. 10
other patients who had no ascites did have
alcoholic cirrhosis.

Which of the following is correct?

1- Positive predictive value is 25/(25+5)

2- Positive predictive value is 25/(25+10)

3- Sensitivity is 25/(25+5)

4- Specificity is 25/(25+5)

5- Specificity is 5/(25+5)

Answer & Comments

Answer: 1- Positive predictive value is
25/(25+5)

The table created should show :

Cirrhosis

No cirrhosis

With Drug

5 ~~\

Without Drug

10 J

PPV is the the no of patients with ascites
confirmed cirrhosis / total no of patients with
ascites, hence 25/(25+5).

Predictive Value Positive

-►

Disease

Sensitivity

Yes

No |

Pos

Test

Neg

Specificity

A -

Predictive Value Negative

[ Q: 1757 ] MRCPass - Statistics

A statistician wants to compare the
significance of cholesterol levels in a group of
200 patients before and after treatment with
a new drug.

What is the most appropriate statistical test?

1- Logistic regression analysis

2- Paired t test

3- Chi square test

4- Kaplan meier curve

5- Likelihood ratios

Answer & Comments

Answer: 2- Paired t test

In a clinical trial where the input variable is
type of treatment - a nominal variable - and
the outcome may be some clinical measure
which is normally distributed, the required
test is then the T-test. The paired t-test and
the Wilcoxon signed-rank test are often
conducted to compare two continuous
outcomes from paired observations. An
assumption underlying these tests is that the
responses from pair to pair are mutually
independent.

^ [ Q: 1758 ] MRCPass - Statistics

A -

* Which test is the best of the
following, to compare two groups of
categorical data, e.g. developed Ml/ did not
develop Ml when a drug or placebo is given?

1- Pearson's correlation coefficient

2- Students t test

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3- Chi square test

4- Wilcoxon rank test

5- Multivariate analysis

Answer & Comments

Answer: 3- Chi square test

Chi-squared tests are used to compare
percentages or proportions of categorical
data. Data such as the above can be organised
into a 2x2 contingency table. From the chi-
squared value a p value is read off a statistical
table (depends on degree of freedom) to give
the degree of significance.

Normally distributed data can be compared
with a Student's t-test. Skewed continuous
data can be compared with a Wilcoxon rank-
sum test or a Mann-Whitney U-test.

^ [ Q: 1760 ] MRCPass - Statistics

f, -

# 200 patients were in a study of

intelligence. Mean IQ scores was 150 and
standard deviation was 15.

What is the coefficient of variation?

1- 5%

2 - 10 %

3- 15%

4- Square root of 15%

5- 20%

Answer & Comments

Answer: 2-10%

Coefficient of variation is expressed in %. The
definition coefficient of variation V =
SD/mean.

[ Q: 1759 ] MRCPass - Statistics

There have been many small reports
showing that a drug used to treat cancer also
caused hypertension.

Which of the following studies would provide
rapid information regarding this fact?

1- Case control study

2- Metanalysis

3- Double blind trial

In this example 15/150 = 10%. It is a statistical
measure of the deviation of a variable from its
mean.

[ Q: 1761 ] MRCPass - Statistics

A new drug for inflammatory bow el
disease has been released. The 5 year
mortality rate with the treatment is 50% and
without the treatment it is 60%.

The absolute risk reduction is :

4- A review article

1- 5%

5- Sequential trial

Answer & Comments

Answer: 2- Metanalysis

2 - 10 %

3- 16%

4- 20%

5- 25%

Metanalysis can be performed when there are
several small studies, the study would take
into account all the data from the studies and
provide good estimate whether an effect was
present. This would also be quicker and more
cost effective than performing a double blind
randomised trial.

Answer & Comments

Answer: 2- 10%

The relative risk reduction is 10% of 60% (ie
without the treatment) which is 16%. The
absolute risk reduction is 60 - 50% which is
10 %.

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[ Q: 1762 ] MRCPass - Statistics

* A blood test for screening heart
failure has been introduced. Out of 300
patients, 100 were found to have heart failure
with echocardiography. When the blood test
is used, 80 patients were found to have heart
failure. 70 of these patients had heart failure
confirmed with echocardiography but 10 did
not.

Which is the positive predictive value of the
blood test?

1- 10/80

2- 70/80

3- 70/100

4- 80/100

5- 70/300

Answer & Comments

Answer: 2- 70/80

The positive predictive value of the number of
true positives (70) out of the positives (80)
detected by blood test. In this case, sensitivity
would be the number of positives detected by
the blood test (70) out of the true number of
positives (100).

Echo shows

Echo does
not show HF

Blood test
positive

Blood test
negative

190

Predictive Value Positive

-►

Disease

Sensitivity

Yes

No |

Pos

Test

Neg

Specificity

4 -

Predictive Value Negative

^ [ Q: 1763 ] MRCPass - Statistics

n -

# A professor wants to use the
students t test to analyse data from a
population.

Which of these features would make the test
inapplicable?

1- Normal distribution

2- Parametric distribution

3- Large standard error

4- Large standard deviation

5- Skewed distribution

Answer & Comments

Answer: 5- Skewed distribution

Parametric tests make the assumption that
the data are normally distributed. The
students t test is parametric, hence it assumes
normal distribution, and cannot be applied if
the distribution is not normal or skew ed.

[ Q: 1764 ] MRCPass - Statistics

A study of implantable cardiac
defibrillators (ICD) against 'no treatment'
reports that there is 5 year mortality due to
ventricular arrhythmias of 2% in the ICD group
compared to 4% in the 'no treatment' group.
There was a 50% reduction in cardiac deaths
on treatment.

What does 50% represent?

1- Absolute risk reduction

2- Relative risk reduction

3- Control event rate

4- Experimental event rate

5- Mortality rate

Answer & Comments

Answer: 2- Relative risk reduction

The relative risk reduction in this case is 2/4
which can be expressed as 50% or 0.5. The

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absolute risk reduction is 2%. The control
event rate is 4% and experimental event rate
is 2%.

[ Q: 1765 ] MRCPass - Statistics

Which of the following describes a
type 1 statistical error in a clinical trial ?

1- The null hypothesis is falsely accepted

2- The null hypothesis is falsely rejected

3- A significant value was not achieved

4- Patients were not randomised

5- The hypothesis was not true

Answer & Comments

Answer: 2- The null hypothesis is falsely
rejected

The null hypothesis claims that there is no
difference between two treatments. A type 1
error is defined as the null hypothesis being
falsely rejected. In practice this means that
the study claims to find a difference that does
not really exist.

hypothesis testing Reality

OUTCOMES

The NuB Hypothesis

Is True

The Alternative
Hypothesis is True

Accurate

Type II Error

1 - (1

The Null Hypothesis

Is True

Type 1 Error

Accurate

The Alternative

1*0

Hypothesis is True

©©

[ Q: 1766 ] MRCPass - Statistics

A study investigates whether a
certain drug A is better alone with the
addition of drug B for ulcerative colitis.

After randomizing the patients , a few patients
on both drug A+B drop out due to side effects.
How should the data be analysed?

1- Exclude the patients from statistical
analysis

2- Assume that the patients did not drop out

3- Include these patient outcomes in the drug
A+B group

4- Recruit more patients in the A+B group

5- Analyse the two groups separately

Answer & Comments

Answer: 3- Include these patient outcomes in
the drug A+B group

The analysis of patients dropping out of a
study should take into account the adverse
effects of a drug (in this case drug B) causing
drop out. Hence even though patients have
dropped out, the 'intention to treat' principle
requires the patients to be analysed even if
they did not receive the treatment.

[ Q: 1767 ] MRCPass - Statistics

* A researcher is trying to design a
study to find out the cause of a rare tropical
disease among Pima Indians in South America.
It is not known whether this disease is caused
by an infection or whether it is inherited.

What study design is most appropriate?

1- Cross sectional

2- Case control

3- Prospective cohort

4- Double blind placebo

5- Randomised controlled

Answer & Comments

Answer: 2- Case control

With rare diseases and exposures, case
control studies are the best option. Although
cohort studies are good for rare exposures,
they are not good for rare diseases.

[ Q: 1768 ] MRCPass - Statistics

A new drug has been shown to
reduce mortality from ovarian cancer from

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20% to 10% in 10 years when compared to the
current chemotherapy used. The cost of this
new drug is £100 per year.

How much extra would a hospital need to
spend to prevent one death in 10 years?

1 - £ 20,000

2 - £ 10,000

3- £2000

4- £1000

5- £100

Which of these conditions would ensure
adequate randomisation?

1- Selection from a tertiary hospital

2- A sample of healthy volunteers

3- Only patients who agree to the study

4- Relatives of a family with the disease

5- Stratified random sample

Answer & Comments

Answer 5- Stratified random sample

Answer & Comments

Answer: 2- £10,000

The absolute risk reduction is 10%. The
number needed to treat is 100/10 which is 10
patients to prevent one death in 10 years. 10
patients in 10 years would cost £100 x 10
patients x 10 years which is £10,000.

[ Q: 1769 ] MRCPass - Statistics

A proposal is being made for a study
to assess the effect of stress on coronary
artery thrombosis.

Which of the following is the best study?

1- Cross over study

2- Case control study

3- Randomised trial

4- Cohort study

5- Population study

Answer & Comments

Answer: 2- Case control study

In assessing for common risk factors, case
control studies are better than cohort studies.

r^-

)

disease,

patients.

[ Q: 1770 ] MRCPass - Statistics

A study of a drug on a certain
is in the first stage of selecting

In order to study a certain disease a certain
group needs to be identified. In a stratified
random sample, groups of interest are
identified first, then randomisation occurs
within those groups need to be performed. An
example of this is in a randomised controlled
trial, is to stratify the groups into separate age
groups before randomising the patients. This
allows the study to see whether the results
are different according to the ages.

[ Q: 1771 ] MRCPass - Statistics

A blood test is being evaluated for
measuring the likelihood of heart failure (HF),
as compared to echocardiography as a gold
standard. In the study, the following results
are obtained.

Blood test positive

negative

Echo - has HF

720

Echo - no HF

890

What is the negative predictive value of the
blood test?

1- 30/750

2- 30/750

3- 890/900

4- 890/10

5- 890/30

Answer & Comments

Answer: 3- 890/900

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Negative predictive value is the number of
true negatives found by a negative blood test,
in this case, 890 / (890 + 10).

[ Q: 1772 ] MRCPass - Statistics

Cholesterol tests were performed on
200 patients with either type I or type II
diabetes.

Which method of analysis would best identify
whether there was a difference in the two
groups of patients?

1- Chi square test

2- Paired students t test

3- Correlation coefficient

4- Mann U Whitney test

5- Kaplan Meier curves

Answer & Comments

Answer: 2- Paired students t test

The paired students t test can be used to
compare two groups of patients with
parametric data (Null hypothesis being that
any difference is due to chance). Parametric
means that it meets certain requirements
with respect to parameters of the population
(for example, the data will be normal - the
distribution parallels the normal or bell curve).
In addition, it means that numbers can be
added, subtracted, multiplied, and divided.

[ Q: 1773 ] MRCPass - Statistics

Which of the following correctly
describes a 95% confidence interval?

1- There is a 95% chance that the value is
statistically significant

2- There is a 95% chance that the true value
falls within the confidence interval

3- There is a 95% chance that the p value is
<0.05

4- There is a 95% chance that the standard
error is correct

5- There is a 95% chance of variability

Answer & Comments

Answer: 2- There is a 95% chance that the true
value falls within the confidence interval

The 95% Cl can be used to describe the
chance that a value, or difference falls within
that interval.

[ Q: 1774 ] MRCPass - Statistics

A study is performed to see if body
surface area (BSA) is related to drug
concentration. 50 subjects were injected with
the same concentration of drug. They also had
their BSA measured.

Which is the most appropriate test to assess
for a correlation ?

1- Pearson's correlation

2- Logistic regresssion

3- Chi square test

4- Unpaired t test

5- Paired t test

Answer & Comments

Answer: 2- Logistic regresssion

Logistic regression allows one to predict a
discrete outcome, such as group membership,
from a set of variables that may be
continuous, discrete, dichotomous, or a mix of
any of these. This would allow us to determine
whether one variable is dependent on
another, in this case whether drug
concentration was dependent on BSA. ANOVA
is an example of logistic regression analysis.

[ Q: 1775 ] MRCPass - Statistics

A large study reports that the 10
year risk of mortality due to stroke is 10% on
placebo and 5% on a drug called Frenzy. It was
concluded that there was a 5% reduction in

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mortality from stroke when Frenzy was
prescribed.

Which of these describes the value of 5%?

1- Significance value

2- Mortality reduction

3- Relative risk reduction

4- Absolute risk reduction

5- Number needed to treat

Answer & Comments

Answer: 4- Absolute risk reduction

In this example, the drug reduces the
incidence of stroke from 10% to 5%.

The relative risk reduction (RRR) is 50%.

The absolute risk reduction (ARR) is 5%.

The control event rate (CER) is 10% and the
experimental event rate (EER) is 5%.

The number needed to treat (NNT) is
100%/5% = 20.

5- Include these patient outcomes in the drug
plus physiotherapy group

Answer & Comments

Answer: 5- Include these patient outcomes in
the drug plus physiotherapy group

This is the principle of 'intention to treat'. It is
possible that the physiotherapy intervention
was unpleasant and hence patients dropped
out.

Intention to treat helps to reduce bias by
including the data from original allocation of
treatment, analyzing the patient in the
treatment group even if they did not complete
the trial.

[ Q: 1776 ] MRCPass - Statistics

A study is designed to investigate
whether a certain drug plus physiotherapy
treatment is better than drug treatment alone
in the management of juvenile chronic
arthritis.

After randomizing the patients, a small
proportion of patients in the physiotherapy
group decide to drop out of the study.

What is the correct way of analysing the
subsequent data?

1- Record the patients as having successful
therapy

2- Record the patients as having failed therapy

3- Extend the trial recruitment to make up
numbers

4- Exclude these patients from all analysis

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[ Q: 1777 ] MRCPass - 2010 January

A 35-year-old man who is known to
have bronchiectasis has a chronic cough. A
sputum sample is sent from the clinic.

What organism is most likely to be isolated?

1- Streptococcus pneumoniae

2- Klebsiella spp.

3- Haemophilus influenzae

4- Moraxella

5- Pseudomonas aeruginosa

Answer & Comments

Answer: 3- Haemophilus influenzae

enzymatically converted to 5-fluorouracil in
the tumor, where it inhibits DN synthesis and
slows growth of tumor tissue. Pancytopenia,
diarrhoea and hand-foot syndrome are main
side effects.

[ Q: 1779 ] MRCPass - 2010 January

Which one of the following is a
contraindication to liver biopsy?

1- INRof 1.4

2- ALT of 250 u/l

3- Platelet count of 110 x 10 9 /l

4- Obesity with BMI of 35 kg/m * 1 2 3 4 5

5- Biliary duct dilatation on the ultrasound

The organisms found most typically causing
ongoing infection in bronchiectasis include
Haemophilus species (47-55% of patients) and
Pseudomonas species (18-26% of patients)

Answer & Comments

Answer: 5- Biliary duct dilatation on the
ultrasound

[ Q: 1778 ] MRCPass - 2010 January

A patient with colorectal cancer has
been commenced on a chemotherapy regime
with Capecitabine and oxaliplatin following
surgery.

What is the main difference between 5 FU and
capecitabine?

1- Capecitabine is used orally

2- Capecitabine has a broader indication

3- Capecitabine causes peripheral neuropathy

4- 5 FU has less side effects

5- 5 FU interacts with warfarin

The best answer here is biliary duct dilatation,
which increases the risk of infection as there
might be cholestasis or cholecystitis.

Many would consider obesity, but it is not an
absolute contraindication.

A short list of contraindications to liver biopsy
are:

Prolonged (>1.6) international normalized
ratio (INR)

The platelet count should exceed 60xl0 A 9/l

There should be no biliary dilatation or major
ascites

Answer & Comments

Answer: 1- Capecitabine is used orally

Capecitabine is the oral equivalent of
intravenous 5 -FU.

Bleeding diathesis (eg, hemophilia)

[ Q: 1780 ] MRCPass - 2010 January

Which is the most common site for
primary cardiac tumours to occur in adults?

Capecitabine (Xeloda, Roche) is an orally-
administered chemotherapeutic agent used in
the treatment of metastatic breast and
colorectal cancers. It is a prodrug, that is

1- Right ventricle

2- Right atrium

3- Left atrial appendage

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4- Left atrium

5- Left ventricle

Answer & Comments

Answer: 4- Left atrium

About 75% of atrial myxomas are in the left
atrial.

The most common site is the fossa ovalis
border in the left atrium.

rash had been present for the last lyear and
had gradually become more extensive. He is
otherwise well.

Whot should be the treatment of choice?

1- Ketoconazole cream

2- Nystatin cream

3- Metronidazole cream

4- Oral terbinafine

5- Oral itraconazole

[ Q: 1781 ] MRCPass - 2010 January

* A 45 year old man presents with
weight loss and breathlessness. He has a past
medical history of heavy alcohol intake and
intravenous drug use. On examination, he has
right sided signs of reduced air entry in the
lung bases.

Answer & Comments

Answer: 1- Ketoconazole cream

The features are suggestive of Pityriasis
versicolor, a skin infection which often
presents as patches of relatively depigmented
skin.

A CXR shows pleural effusion on the right side.
Chest aspiration was attempted by the senior
house officer but this was unsuccessful.

What is the next investigation?

1- Lateral Chest X Ray

2- Bronchoscopy

3- CT of the chest

The cause is overgrowth of the yeast
Malassezzia furfur.

Topical antifungal medications are the
treatment of choice for Tinea/ Pityriasis
versicolor. The following topical antifungal
treatment regimens have been shown to
produce a greater than 70% clinical response
rate:

4- Lung function test

5- Ultrasound of the chest

Answer & Comments

Answer: 5- Ultrasound of the chest

This patient has a failed aspiration of the
chest.

However, he is at high risk of empyema and so
priority is still to get an aspirate sample
through ultrasound guidance.

^ [Q: 1782] MRCPass-2010 January

* A 25 year-old man presents with
extensive, coalescing, hypopigmented, slightly
scaly lesions on his face and the scalp. The

2% Ketoconazole cream and ketoconazole
shampoo

Selenium sulphide suspension (Selsun
shampoo)

[ Q: 1783 ] MRCPass - 2010 January

A 31-year-old man who is known to
be HIV positive presents with dyspnoea and a
dry cough. Is last CD4 count was 150 cells/pl.
Clinical examination reveals a respiratory rate
of 24 / min. Chest auscultation reveals fine
crackles bilaterally. His oxygen saturation is
98% on room air but this desaturates to 85%
after walking the length of the ward. A chest x
ray shows fine infiltrates in both lower zones.

What is the most appropriate first-line
treatment?

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1- Fluconazole

2- Co-trimoxazole

3- Clarithromycin

4- Ganciclovir

5- Sulfadiazine and pyrimethamine

Answer & Comments

Answer: 2- Co-trimoxazole

Pneumocystis pneumonia (PCP) is caused by
the yeast-like fungus previously classified as a
protozoan Pneumocystis jirovecii.

The risk of pneumonia due to Pneumocystis
jirovecii increases when CD4 counts are
lessthan 200 cells/?l.

There is increased opacification in the lower
lungs on both sides, characteristic of
Pneumocystis pneumonia.

Antipneumocystic medication (classically co-
trimoxazole) is used with concomitant steroids
in order to avoid inflammation.

was

[ Q: 1784 ] MRCPass - 2010 January

A 55-year-old, unemployed, man
admitted due to confusion and

disorientation with the onset of acute
symptoms a few days before admission. He
had a history of alcohol dependence of 20
years duration. He was aw ake but
disorientated to person, location, situation,
and time.

Temperature was 36.5 C and BP was 120/80
mmHg. Neurological examination revealed
gaze-evoked nystagmus in all directions. All
deep tendon reflexes were normal. The finger-
nose test was ataxic. Standing and gait with
open eyes evidenced a distinct ataxia with
tremors of the upper extremity. The Romberg
sign was positive. He had an MMSE score of
26 /30 on admission. A blood glucose
measurement was 3 mmol/I.

Whot should be given to treat the patient?

1- 50 ml of 50% dextrose

2- 500 mis of 5% dextrose

3- Thiamine infusion

4- Lactulose

5- Chlordiazepoxide

Answer & Comments

Answer: 3- Thiamine infusion

This patient is exhibiting features of
Wernicke's encephalopathy, which are
nystagmus, ataxia and confusion.

The daily thiamine requirement for healthy
individuals is between 1 and 2 mg/day but
both alcohol and malnutrition may interfere
with the absorption of thiamine. Thiamine
dependent enzymes such as transketolase and
pyruvate dehydrogenase are essential for
cerebral myelination and thiamine deficiency
in alcoholism leads to Wernicke's
encephalopathy.

Thiamine should also be supplemented fully in
malnourished alcoholics. The administration
of intravenous fluids containing glucose
without adequate thiamine supplementation
in alcoholics could aggravate the thiamine

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deficiency leading to irreversible cerebral
lesions.

What is the most appropriate course of
action ?

[ Q: 1785 ] MRCPass - 2010 January

A 43 year old man had a cough and
his GP organized a chest X ray. This showed a
pneumothorax and he was referred to the
hospital. He does not have any symptoms of
breathlessness or chest pains. His BP was
110/80 mmHg, 02 sats were 99% on air &
pulse was 80/min. CXR shows that there is a
pneumothorax on the left with a 1 cm margin
from the rim.

Which is the most appropriate step?

1- Chest drain

2- Surgical referral

3- CT scan of the chest

4- Discharge with outpatient follow up

5- needle aspiration

Answer & Comments

Answer: 4- Discharge with outpatient follow
up

The British thoracic society recommends that
a small pneumothorax of < 2 cm rim, with no
significant symptoms to be managed
conservatively (discharge with outpatient
review and advise to return if breathlessness
occurs).

[ Q: 1786 ] MRCPass - 2010 January

A 60-year-old has developed an
I hernia and is keen for surgical repair.

The anaesthetist refers the patient for
assessment in outpatients. His history includes
a previous who had a drug-eluding stent
inserted 6 months ago. His current medication
includes aspirin, clopidogrel, atorvastatin,
ramipril and bisoprolol. The cardiologists plan
was to continue clopidogrel for 12 months
following stent insertion.

inguina

1- Stop clopidogrel the day before the
operation

2- Stop clopidogrel 1 week before the
operation

3- Stop clopidogrel the day prior to the
operation andstart low-molecular weight
heparin (prophylaxis dose)

4- Continue clopidogrel throughout the
perioperative period

5- Delay surgery for 6 months

Answer & Comments

Answer: 5- Delay surgery for 6 months

There is a risk of stent thrombosis with
discontinuing clopidogrel.

For non urgent surgery this should be delayed
till a 12 month period on clopidogrel has
elapsed. If the patient required urgent surgery
e.g. acute abdomen or incarcerated hernia,
then the clopidogrel would have to be
discontinued prior to surgery, with a
discussion between surgeons and cardiologists
weighing risks of bleeding during surgery vs
stent thrombosis.

[ Q: 1787 ] MRCPass - 2010 January

A 70 year old lady presents with hip
pain on the right side. She has a history of
hypertension. On examination, she is able to
mobilise and has normal flexion and extension
of movement of her hip. She is However,
tender to the palpation in the right lateral hip.

What is the likely diagnosis?

1- Osteoarthritis

2- Ankylosing spondylitis

3- Rheumatoid arthritis

4- Trochanteric bursitis

5- Fracture of neck of femur

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Answer & Comments

Answer: 4- Trochanteric bursitis

but was not a given option for this question in
the exam.

Trochanteric bursitis is characterized by
painful inflammation of the bursa located just
superficial to the greater trochanter of the
femur.

Patients typically complain of lateral hip pain,
although the hip joint itself is not involved.
The pain may radiate down the lateral aspect
of the thigh. It may occur with trauma. Rest
and physiotherapy are best management
options, although steroid injection is an
option.

[ Q: 1788 ] MRCPass - 2010 January

A 55-year-old woman is investigated
for progressive shortness of breath. On
examination a loud P2 is noted associated
with a left parasternal heave. An ECG shows
evidence of right ventricular strain and a
diagnosis of pulmonary hypertension was
suspected.

Which one of the following is the most
important test to confirm the diagnosis?

1- High resolution CT thorax

2- Chest X Ray

3- Echocardiography

4- Pulmonary angiography

5- Ventilation perfusion scanning

Answer & Comments

Answer: 3- Echocardiography

[ Q: 1789 ] MRCPass - 2010 January

A 40-year-old man who was
diagnosed with type 2 diabetes mellitus
presents for review in the clinic. His current
medication is metformin and gliclazide. His
blood results were as follows:

Total cholesterol 5.8 mmol/l
HDL cholesterol 1.2 mmol/l
LDL cholesterol 3.5 mmol/l
Triglyceride 1.7 mmol/l
HbAlc 6.6%

According to recent NICE guidelines, what is
the most appropriate action?

1- Atorvastatin 40mg nocte

2- Simvastatin 40mg nocte

3- Dietary advice

4- Clofibrate

5- Nicotinic acid

Answer & Comments

Answer: 2- Simvastatin 40mg nocte

NICE guidelines suggest target lipid levels of
4:2 in diabetic patients (ie. Total cholesterol of
< 4 and LDL of < 2). The guidelines also
recommend the most cost effective statins to
be commenced first (simvastatin £4 per
month compared to £40 per month for
atorvastatin until it comes off patent which it
does in 2010).

The tests are all useful, However the best
option is echocardiography, which can provide
an estimate of pulmonary arterial pressure,
identify right ventricular strain and also
exclude any congenital heart disease.

Right heart cardiac catheterisation is most
accurate as accurate pulmonary arterial
pressures can be measured with a transducer,

[ Q: 1790 ] MRCPass - 2010 January

You are reviewing a patient's urea
and electrolyte results. There appears to be a
discrepancy between the serum creatinine
and the calculated eGFR.

Which one of the following factors is most
likely to explain this discrepancy?

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1- Diuretic use

2- Pregnancy

3- Type 1 diabetes mellitus

4- Significant hypertension

5- Female gender

Answer & Comments

Answer: 2- Pregnancy

with positive direct sputum smears should be
isolated in negative pressure rooms.

[ Q: 1792 ] MRCPass - 2010 January

On the ECG, which one of the
following features is seen with significant
Hypokalaemia?

1- Flattened p wave

2- Flattened t wave

When a person's creatinine is stable, an
estimated Glomerular filtration rate can be
obtained with inputs of creatinine, age,
gender and racial origin.

3- Prominent u wave

4- Prominent j wave

5- Prominent r wave

The eGFR estimate may be inaccurate in
people over 70 years of age, people less than
18 years old, pregnancy, amputees,
malnourishment and dehydration states.

[ Q: 1791 ] MRCPass - 2010 January

A 35 year old man is admitted with
fevers, cough and night sweats.

Which one of the following test results
suggests that he needs isolation into a side
room in the hospital?

1- Positive sputum culture for TB

2- Positive sputum direct smear for TB

3- Positive CSF culture for TB

4- Positive urine culture for TB

5- Positive urine direct smear for TB

Answer & Comments

Answer: 2- Positive sputum direct smear for
TB

Answer & Comments

Answer: 3- Prominent u wave

The prominent U wave is a component seen
after a T wave seen in severe Hypokalaemia.

i—-r

i 11

ft If HP

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U If

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fTTTtYTTTf

J J

"Tir 1

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rH^TTHHri

lnr—|p-f~v

HrHr

T 7

U waves

[ Q: 1793 ] MRCPass - 2010 January

A 40 year old woman has been
complaining of polyuria and polydipsia and
presents to the clinic for assessment.

Her body mass index (BMI) was 42 kg/m2.

Stained smears of sputum specimens to detect
the presence of acid fast bacilli (AFB) are
useful diagnostic tools in the management of
tuberculosis.

Patients with tuberculosis who have negative
sputum smears for AFB are less contagious
than patients with positive smears. Patients

A 75g oral glucose tolerance test shows the
following results

Time Plasma glucose concentration
0 hour 5.5 mmol/I
2 hour 15 mmol/l

Which of the following is the appropriate next
step in the patient’s management?

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1- Fasting glucose tolerance test

2- Gliclazide

3- Subcutaneous insulin

4- Diet control

5- Metformin

Answer & Comments

Answer: 5- Metformin

Metformin is a biguanide drug used in
diabetes.

It improves hyperglycemia primarily through
its suppression of hepatic glucose production
and increases insulin sensitivity. This patient
has type 2 diabetes (late onset) is overw eight.
Metformin is the first-line drug of choice for
the treatment of type 2 diabetes, particularly
in overweight and obese people and those
with normal kidney function.

[ Q: 1794 ] MRCPass - 2010 January

A 50 year old man with Type 2
diabetes is currently on metformin 500mg tds.
He is a muslim and prior to Ramadan, he seeks
advice about managing his glycaemic control.
He is concerned that he already has early
diabetic retinopathy.

What should be done?

by increased dosage in the evening to combat
hyperglycaemia and reduced dosage in early
morning to prevent hypoglycaemia.

Hence the best answer is for the patient to
increase the metformin dose in the evening to
1 g and carry on with a morning dose of 500
mg in the morning.

[ Q: 1795 ] MRCPass - 2010 January

A 62 year old woman has recently
had lethargy and arthralgia. She was
diagnosed as having influenza infection, as
there was an outbreak in the area recently.
She presents 1 week later with a cough and
breathlessness. On examination, she had
bilateral crackles audible on examination. CXR
confirms bilateral consolidation.

Which one of the following is most likely os o
couse?

1- Legionella

2- Mycoplasma

3- Streptococcus pneumoniae

4- Klebsiella

5- staphylococcus aureus

Answer & Comments

Answer: 5- staphylococcus aureus

1- Advise the patient not to fast

2- Change metformin dose to 500mg am and
lg in the evening

3- Change metformin to gliclazide 160 mg am
and 80 mg in the evening

4- Change to insulin 12 units tds

5- Change to glargine insulin 22 units at night

Answer & Comments

Answer: 2- Change metformin dose to 500mg
am and lg in the evening

Most diabetics can safely fast but more
medical attention to adjust their medication

Normal incidence of staph aureus pneumonia
is 2%, However this is significantly increased in
iv drug users and influenzae virus infections.

Post influenzae staph aureus pneumonia is
characterised by rapid clinical deterioration
with septicaemia.

[ Q: 1796 ] MRCPass - 2010 January
A 75-year-old man on the surgical

wards develops chest pain. He is three days
post-op following a colectomy for colocolon
cancer (Duke's C). He is currently on a
prophylactic low molecular weight heparin. An
ECG performed by the nurses shows ST

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elevation in the anterior leads. Aspirin and
oxygen have been given.

Whot is the most appropriate treatment now?

1- Increase low-molecular weight heparin

2- Start unfractionated heparin

3- Arrange for primary angioplasty

4- arrange echocardiogram urgently to
exclude pericardial tamponade

5- Thrombolysis with tenecteplase

Answer & Comments

Answer: 2- Imatinib

The diagnosis here is chronic myeloid
leukaemia, which accounts for 20% of all
leukaemias.

It occurs mainly in middle aged and elderly
people and is characterised by marked
leucocytosis, a left shifted myeloid series and
in 95% of patients, the Philadelphia
chromosome.

Answer & Comments

Answer: 3- Arrange for primary angioplasty

There is no contraindication to acute coronary
intervention in this case, as the prognosis of a
patient with colorectal cancer post surgery is
good.

Hence, primary PCI is the preferred option.

[ Q: 1797 ] MRCPass - 2010 January

A 60-year-old woman is investigated
for weight loss, fatigue and anaemia. She has
no past medical history of note. Clinical
examination reveals splenomegaly associated
with pallor. A full blood count is reported as
follows:

Hb 9.8 g/dl
Platelets 380 x 10 9 /l
WCC 120 x 10 9 /l

Blood film. Demonstrates left shift with
predominating myelocytes. Low percentage of
blast cells.

What is the most appropriate treatment?

1- Chlorambucil

2- Imatinib

3- Thalidomide

4- Rituximab

Imatinib is recommended as first-line
treatment for people with Philadelphia-
chromosome-positive chronic myeloid
leukaemia (CML) in the chronic phase With
disease progression and palliative situations,
Imatinib is used in combination with
recombinant alpha interferon, hydroxyurea
and busulphan.

[ Q: 1798 ] MRCPass - 2010 January

A 50-year-old woman presents with
a variety of physical symptoms that have been
present for the past 8 years, following her
mother's death. She has been complaining of
tremors, sensory disturbances and fits
occurring several times a day. Numerous
investigations and review by a variety of
specialties have indicated no organic basis for
her symptoms.

What is the diagnosis?

1- Munchausen's syndrome

2- Hypochondrial disorder

3- Dissociative disorder

4- Somatisation disorder

5- Conversion disorder

Answer & Comments

Answer: 5- Conversion disorder

5- Hydroxycarbamide

The history fits a diagnosis of conversion
disorder as below.

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Munchausen syndrome (factitious disorder):
the patient seeks medical attention by the
deliberate production or feigning of
symptoms.

The motivation for seeking attention is not
known.

Hypochondriasis: (somatoform disorder) the
patient is convinced that they have a life-
threatening illness, despite evidence to the
contrary. The core feature of hypochondriasis
is not preoccupation with symptoms
themselves, but rather the fear or idea of
having a serious disease. The fear or idea is
based on the misinterpretation of bodily signs
and sensations as evidence of disease.

4- Losartan

5- Nifedipine

Answer & Comments

Answer: 2- Methyldopa

Beta blockers are safe in third trimester of
pregnancy, but are generally not used due
fears of IUGR.

Generally, one would favour labetalol in these
circumstances given there an evidence base
its use. Nifedipine may be used by
experienced clinicians, but currently
unlicensed. There is good evidence that
methyldopa effective and safe in pregnancy.

Somatisation disorder:(somatoform disorder)
With this a patient presents with multiple,
medically unexplained symptoms. The
patient's life or work are frequently affected,
although they also might be unconcerned
about the nature of their symptoms (thus
appearing calm). It is not a deliberate feigning
of symptoms.

Conversion disorder : (somatoform

disorder)This is a condition where a patient
displays neurological symptoms e.g. paralysis,
even though no neurological explanation is
found and it is determined that the symptoms
are due to the patient's psychological
response to stress.

[ Q: 1800 ] MRCPass - 2010 January

A right- handed woman presented
with difficulty reading. She was investigated
with a CT brain which showed right sided
parietal lobe infarction.

Which of the following is likely to be
contributing to her reading difficulty?

1- Agraphia

2- Acalculia

3- Left right disorientation

4- Visual inattention

5- Hemianopia

^ [ Q: 1799 ] MRCPass - 2010 January

fit -

# A woman who is 33 weeks pregnant
is admitted to the obstetric ward. She has
been monitored for the past few weeks due to
pregnancy-induced hypertension but has now
developed proteinuria. Her blood pressure is
160/95 mmHg.

Which one of the following ontihypertensives
is most appropriate?

1- Atenolol

2- Methyldopa

3- Moxonidine

Answer & Comments

Answer: 4- Visual inattention

This patient is right handed, hence the left
brain is dominant, and the right parietal lobe
infarct is in the non dominant hemisphere.

Tests for dominant inferior parietal lobe
function includes right-left orientation,
naming fingers, and calculations and
Gerstmann syndrome describes dominant
lobe signs. A mnemonic for the signs is ALF
(acalculia / agraphia, left right disorientation
and finger agnosia).

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The non-dominant parietal lobe is important
for visual spatial sensory tasks such as
attending to the contralateral side of the body
and space as well as constructional tasks such
as drawing a face, clock or geometric figures.
A non dominant lesion leads to visual
inattention and dyspraxia (unable to
coordinate motor tasks).

[ Q: 1801 ] MRCPass - 2010 January

A 65 year old lady has hypertension
and is currently on with several medications.
Over the last few months, she has been
complaining of worsening ankle oedema and
fatigue.

Which drug is likely to hove coused this?

1- Monoxidine

2- Ramipril

3- Amlodipine

4- Doxazosin

5- Indapamide

Answer & Comments

Answer: 3- Amlodipine

Ankle oedema is commonly caused by calcium
channel blockers.

Answer & Comments

Answer: 4- Right coronary artery

The diagnosis is an inferior myocardial
infarction with complete heart block, this is
most commonly due to a RCA lesion.

[ Q: 1803 ] MRCPass - 2010 January

A 60-year-old man has been on
haemodialysis for chronic kidney disease for
the past 5 years.

He is currently on dialysis 3 times a week. For
a patient on haemodialysis, whot is the most
likely eventual couse of death?

1- Hyperkalaemia

2- Dilated cardiomyopathy

3- Dialysis related sepsis

4- Ischaemic heart disease

5- Renal carcinoma

Answer & Comments

Answer: 4- Ischaemic heart disease

Cardiovascular disease, infection and
hyperkalaemia are common causes of death,
with ischaemic heart disease being the most
likely.

[ Q: 1802 ] MRCPass - 2010 January

A 47 year old patient had chest pain.

His ECG showed ST elevation in the leads II, III,
aVF and he also had no correlation between p
waves and QRS complexes.

Which artery is likely to be affected?

1- Left main stem

2- Left anterior descending

3- Circumflex

4- Right coronary artery

5- Diagonal

The 10 year survival rate is 50%.

[ Q: 1804 ] MRCPass - 2010 January

/ -

* A 30 year old lady has a history of

ventricular septal defect. She wishes to
become pregnant and is undergoing cardiac
assessment.

Which one of the following complications is
associated with the highest risk?

1- Polycythaemia

2- High pressure gradient across VSD

3- Pulmonary hypertension

4- Aortic regurgitation

5- Overriding aorta

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Answer & Comments

Answer: 3- Pulmonary hypertension

Pulmonary hypertension with a VSD can lead
to shunt reversal (Eisenmenger's syndrome).

This will lead to significant hypoxia and can
confer significant risk to oxygenation of the
fetus during pregnancy.

[ Q: 1805 ] MRCPass - 2010 January

A 32-year-old female presents
complaining of a purpuric rash on the back of
her legs but is otherwise asymptomatic. She
has no significant past medical history and has
not been on any medications recently. A urine
dipstick is normal. Her blood results are:

Hb 11.3 g/dl

Platelets 30 x 10 9 /l

WCC 5.3xl0 9 /l

PT 13 secs

APTT 30 secs

sodium 135 mmol/l

potassium 4.5 mmol/l

urea 5 mmol/l

creatinine 100 pmol/l

What is the most likely diagnosis?

1- Drug-induced thrombocytopenia

2- Henoch-Schonlein purpura

3- Idiopathic thrombocytopenic purpura

4- Thrombotic thrombocytopenic purpura

5- Systemic lupus erythematosus

Answer & Comments

Answer: 3- Idiopathic thrombocytopenic
purpura

The two most likely answers are either HSP or
ITP due to the purpuric rash.

HSP is associated with other vasculitic
phenomena such as renal involvement and

abdominal vasculitis. It is also not associated
with a low platelet count as in this case, hence
ITP is the most likely diagnosis.

^ [ Q: 1806 ] MRCPass - 2010 January

* A 25 year old man presented with a
purpuric rash. He has a history of asthma but
otherwise was previously well. On
examination, he had small areas of non
blanching purpura around the arms and legs.
Cardiac, respiratory, abdominal and
neurological examinations were normal. The
following results were obtained:

Hbl2 g/dl

WCC 8 x 10 9 /l

Platelets 18 x 10 9 /l

What treatment should be given?

1- Blood transfusion

2- Splenectomy

3- Prednisolone

4- Platelet transfusion

5- Intravenous immunoglobulin

Answer & Comments

Answer: 3- Prednisolone

This patient has idiopathic thrombocytopenic
purpura.

The underlying pathology is antibodies against
platelets.

Bleeding from the gums, epistaxis and
purpuric lesions on the skin are typical
manifestations. The platelet count is low . The
patient should be treated with prednisolone
(usually a high dose e.g. 60 mg) with gradual
tapering down once the platelet count rises. If
prednisolone does not bring a response, then
intravenous immunoglobulin can be
administered. Patients with recurrent
episodes of low platelet counts despite
steroids can be considered for splenectomy.

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4^ [ Q: 1807 ] MRCPass - 2010 January

* A 42-year-old man has recently
started treatment for tuberculosis. He is
complaining of a deterioration in his vision. On
examination, his visual acuity in the right eye
is 6/18 on the right and 6/12 on the left eye.

Which one of the following drugs is most likely
to be implicated?

1- Rifampicin

2- Isoniazid

3- Pyrazinamide

4- Ethambutol

5- Streptomycin

4- Anxiety disorder

5- Obsessive compulsive disorder

Answer & Comments

Answer: 3- Drug induced psychosis

It is well established that psychotic symptoms
may follow cannabis intake.

Patients who present with these symptoms
may get better and be diagnosed with
schizophrenia at a later stage. Patients can
present with a range of symptoms including
agitation, depression, visual and auditory
hallucinations.

Answer & Comments

Answer: 4- Ethambutol

The standard treatment for tuberculosis is a 6-
month, four-drug initial regimen (6 months of
isoniazid and rifampicin supplemented in the
first 2 months with pyrazinamide and
ethambutol).

Ethambutol is associated with optic neuritis
(visual deterioration) and colour blindness.

[ Q: 1808 ] MRCPass - 2010 January

A 16 year old student is behaving
strangely and referred to the hospital. His
teacher reports that he was accused the
teacher of conspiring against him. He was also
hearing voices asking him to cut his own
throat. He has not been himself recently, with
low moods according to his family. On
examination, he looks apathetic and physical
examination is normal. Blood tests were
unremarkable, and urine testing showed
traces of cannabinoids.

Whot is the likely diagnosis?

1- Psychotic depression

2- Paranoid schizophrenia

3- Drug induced psychosis

^ [ Q: 1809 ] MRCPass - 2010 January

/ -

# A 22-year-old man presents with a

painful joints. He returned 1 week ago from a
holiday in Spain. Initially he had joint sw
ellings in both wrists and now he has a left
knee sw elling. There is no history of trauma
and he has had no knee problems previously.
On examination he has a swollen, warm left
knee with a full range of movement.

His ankle joints are also painful to move but
there is no sw elling. There was also a rash on
the soles of the feet with very small vesicles. A
joint aspirate was done and it showed no
organisms but had increased white cells.

What is the most likely diagnosis?

1- Rheumatoid arthritis

2- Psoriatic arthritis

3- Gout

4- Reactive arthritis

5- Gonococcal arthritis

Answer & Comments

Answer: 5- Gonococcal arthritis

This patient with no past medical history is
likely to have a reactive arthritis or septic
arthritis due to gonococcal infection.

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The history above is more consistent with
gonococcal arthritis with the bacteremic form
(classic triad of migratory polyarthritis,
tenosynovitis, and dermatitis).

The patient has migratory polyarthritis with
knee sw elling. The arthralgias are typically
asymmetric and tend to involve the upper
extremities more than the lower extremities.
The wrist, elbows, ankles, and knees are most
commonly affected.

The ankle pains with no sw elling suggests
tenosynovitis. The tenosynovitis of DGI is
asymmetric and most commonly occurs over
the dorsum of the wrist and hand, as well as
over the metacarpophalangeal joints, ankles,
and knees. The rash associated with the
bacteremic form of DGI may be overlooked by
patients because it is painless and nonpruritic
and consists of small papular, pustular, or
vesicular lesions.

[ Q: 1810 ] MRCPass - 2010 January

A 16 year old female is evaluated in
the pediatric endocrinology clinic for primary
amenorrhoea.

A person with complete androgen insensitivity
syndrome (CAIS) has a female external
appearance despite a 46XY karyotype and
undescended testes. This is due to the lack of
sensitivity to androgen (testosterone) leading
to a failure of male physical development.

Many of these patients have a female
phenotype. Some patients are first seen in the
teenage years for evaluation of primary
amenorrhea, but most are identified in the
new born period by the presence of inguinal
masses, which later are identified as testes
during surgery. The patients also have a male
level of testosterone and may have
clitoromegaly or a micropenis.

[ Q: 1811 ] MRCPass - 2010 January

A statistician is advising a research
about a study of blood pressures in a specific
ethnic population. The researcher is
concerned about the spread of blood
pressures being larger than in the general
population, hence affecting the sample mean.

Which of these measures provides an estimate
of this concept?

Which one of these features is consistent with
testicular feminisation or androgen
insensitivity syndrome?

1- Male phenotype with lack of hair

2- Male phenotype with inguinal testis

3- Male phenotype with breast development

4- Female phenotype with clitoromegaly and
undescended testis

5- Female phenotype with external male
genitals

1- Sensitivity

2- Specificity

3- Positive predictive value

4- Negative predictive value

5- Standard error of mean

Answer & Comments

Answer: 5- Standard error of mean

Standard deviation provides a measure of
spread of observations about mean.

Answer & Comments

Answer: 4- Female phenotype with

clitoromegaly and undescended testis

Androgen insensitivity syndrome (AIS),
formerly known as testicular feminization, is
an X-linked recessive condition.

It based of deviation of each observation from
the mean value. Standard error of the mean is
the standard deviation of the sampling
distribution of the mean - which gives an
estimate of how close the sample mean is to
the true population mean. It increases with

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sample size and increases with standard
deviation.

The S.E.M. is the standard deviation divided by
the square root of the sample size SEM = ? /
?N where ? is the standard deviation of the
original distribution and N is the sample size.

[ Q: 1812 ] MRCPass - 2010 January

A 40 year old Caucasian female
presented with malaise, dysphagia and
sclerodactyly and Raynaud's phenomenon for
the last 3 months. On physical examination
she was afebrile and had a supine blood
pressure of 110/80mm Hg. Sclerodactyly and
telangiectasia were observed in both hands.
Blood tests revealed:

Hb 11.5 g/dl, MCV 85 fl

erythrocyte sedimentation rate of 80 mm/first
hour,

antinuclear antibody (ANA) - strongly positive

antitopoisomerase I antibody (formerly anti
SCL-70 antibody) positive

normal C3 and C4

anti-DNA, anti-centromere, anti-RNP, anti-Ro
and La antibodies - negative

Chest x-ray showed bilateral basilar interstitial
infiltrates.

What is the diagnosis?

1- Hereditary haemorrhagic telangiectasia

2- Sarcoidosis

3- Wegener's granulomatosis

4- Oesophageal carcinoma

5- Scleroderma

develop it during the course of their disease.
Oesophageal dysmotility may cause reflux,
aspiration or dysphagia. Pulmonary fibrosis
and renal impairment are also associated.

Antinuclear antibodies are present in about
95% of the patients. Topoisomerase I
antibodies (formerly Scl-70) are present in
approximately 30% of patients with diffuse
disease (absent in limited disease) and are
associated with pulmonary fibrosis.
Anticentromere antibodies are present in
about 60-90% of patients with limited disease
and are rare in patients with diffuse disease
(which is more likely in this case).

[ Q: 1813 ] MRCPass - 2010 January

In which one of the following areas
does polypeptide degradation take place?

1- Golgi body

2- Peroxisome

3- Proteosome

4- Endoplasmic reticulum

5- Ribosome

Answer & Comments

Answer: 3- Proteosome

The proteosome is a large complex of various
proteases, proteins / polypeptides that break
down other proteins in specific ways.

The proteins are usually tagged by ubiquitin
before they can be degraded by proteases.

Peroxisomes participate in the breakdown of
fatty acids.

Answer & Comments

Answer: 5- Scleroderma

The clues here for scleroderma are dysphagia,
sclerodactyly and Raynaud's phenomenon.

70% of patients initially present with
Raynaud's phenomenon; 95% eventually

^ [ Q: 1814 ] MRCPass - 2010 January

/ ■ ---

# An 18-year-old man presents with

lethargy, pyrexia and headaches. These
symptoms have been present for the past 8
days. He had not been unwell before and
there is no recent history of travel. Clinical
examination reveals a temperature of 37.9°C,

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marked cervical lymphadenopathy and mild
hepatomegaly. Throat examination reveals
two small erythematous areas. A full blood
count result shows:

Hb 13.1 g/dl

Platelets 225 x 10 9 /l

WCC 17.1 x 10 9 /l

Neut 5.2 x 1071

Lymp 11.2 x 1071

Blood Film Atypical lymphocytes seen
What is the most likely diagnosis?

1- Acute lymphoblastic leukaemia

2- Hashimoto's thyroiditis

3- Infectious mononucleosis

4- HIV seroconversion

5- Septicaemia secondary to streptococcal
throat infection

Answer & Comments

Answer: 3- Infectious mononucleosis

The history of previously being well, acute
deterioration with lymphadenopathy, throat
involvement and atypical lymphocytes on
blood film are all consistent with Epstein Barr
virus infection (glandular fever or infectious
mononucleosis).

Atypical lymphocytes are commonly
associated with EBV, CMV and toxoplasma
infection.

Reactive lymphocytes are lymphocytes that
become large as a result of antigen
stimulation.

[ Q: 1815 ] MRCPass - 2010 January

A 40-year-old man with a history of
bipolar disorder is admitted with acute
confusion. On examination, had has tremors
and was observed to have diarrhoea. He is
suspected of having lithium toxicity.

Which one of the following drugs is most likely
to have precipitated this?

1- Paracetamol

2- Steroids

3- Ramipril

4- Penicillins

5- Antimalarials

Answer & Comments

Answer: 3- Ramipril

Lithium toxicity can be precipitated
particularly by thiazide diuretics and ACE
inhibitors.

Other drugs which can interact are
anticonvulsants, antidepressant (SSRI),
phenothiazines, NSAIDS and calcium channel
blockers drugs.

[ Q: 1816 ] MRCPass - 2010 January

A 62 year woman diabetes mellitus
presented sudden onset of wild flinging
movements of left arm which disturbed her
during sleep at night.

Where is the likely site of the lesion?

1- Substantia nigra

2- Contralateral subthalamic nucleus

3- Non dominant parietal

4- Caudate nucleus

5- Cerebellar

Answer & Comments

Answer: 2- Contralateral subthalamic nucleus

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The hemiballismus (swinging arm movements)
is likely be due a vascular event in the
subthalamic nucleus.

[ Q: 1817 ] MRCPass - 2010 January

A 60-year-old man is admitted to the
resuscitation room with a GCS score of 13/ 15.

He has a past medical history of hypertension,
glaucoma and diabetes. He had been found
unconscious at home.. Blood gases and blood
test results taken on admission show the
following:

pH 7.22
pC02- 3.5 kPa
p02 -13.8 kPa
Na+ 140 mmol/I

K+ 4.2 mmol/l

Chloride 110 (95-107) mmol/l
Bicarbonate 10 (20-28) mmol/l
Urea 2.1 mmol/l
Creatinine 79 |imol/l
Glucose 7.1 mmol/l

A day following observation in the assessment
unit, he complained of visual problems.

Which one of the following diagnoses would
be most consistent with these results?

1- Addisonian crisis

2- Pulmonary embolism

3- Paraquat poisoning

4- Methanol poisoning

5- Diabetic ketoacidosis

Answer & Comments

Answer: 4- Methanol poisoning

This patient has a raised anion gap and
metabolic acidosis.

The anion gap is = (Na + K) - (CI+HC03),
[normal range

10-18 mmol/L]. In this case (140 + 4.2) - (110 +
10) = 24.2

Methanol poisoning can cause high anion gap
metabolic acidosis and also leads to formation
of formic acid from methanol, which causes
retinal toxicity and visual impairment.

A useful mnemonic to remember causes of
high anion gap metabolic acidosis is MUDPILES
(methanol, uremia, DKA, propylene glycol,
isoniazid, lactic acidosis, ethylene glycol,
salicylates). The scenario is not consistent with
diabetic ketoacidosis ad the glucose is normal.

[ Q: 1818 ] MRCPass - 2010 January

A 58 patient has been admitted with
confusion and tremors. There was no clear
history available, hence the patient was kept
in hospital for observation.

Which one of the following features supports
the diagnosis of alcohol withdrawal?

1- History of long term memory loss

2- History of epilepsy

3- Use of cannabis

4- Seeing a dog lying next to the bed

5- Obsessive hand washing

Answer & Comments

Answer: 4- Seeing a dog lying next to the bed

Alcohol withdrawal delirium (delirium
tremens) - this is the clinical syndrome of
disorientation, perceptual disturbance and
psychomotor agitation.

Visual hallucinations are commonly
associated, as suggested I this case where the
patient sees a dog in the hospital.

Korsakoff's associated short term memory
loss, subsequent compensatory confabulation
by patient. Other symptoms may include
delirium, anxiety, fear, depression, confusion,
delusions and insomnia.

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[ Q: 1819 ] MRCPass - 2010 January

A 40-year-old woman who is known
to be HIV positive is admitted to the
Emergency Department following a seizure.
Her partner reports that she has been having
headaches, night sweats and anorexia for the
past four weeks. Blood tests and a CT head are
arranged:

CD4 80 cells/mm

CT head - Single ring enhancing lesion in the
right parietal lobe with surrounding oedema

What is the most likely diagnosis?

1- CNS lymphoma

2- Tuberculosis

3- Progressive multifocal

leukoencephalopathy

4- Brain abscess

5- Cerebral toxoplasmosis

Answer & Comments

Answer: 1- CNS lymphoma

The best options are either lymphoma or
toxoplasmosis, but key to differentiating is
whether it is single or multiple.

With cerebral lymphoma, a single lesion that
enhances in a nodular, homogeneous, or ring
like pattern is observed, typically with
surrounding cerebral oedema.

Toxoplasmosis is the most common cause of
brain lesions in HIV patients.

The majority of lesions (90%) are However,
mulltiple on presentation, so is less likely in
the above scenario.

Tuberculous infection is much more varied
radiologically, with meningeal destruction and
Granulomas.

Cerebral Lymphoma

[ Q: 1820 ] MRCPass - 2010 January

A 40 year old woman is admitted to
the Emergency Department with pleuritic
chest pain and haemoptysis, ten days
following surgery. She has oxygen saturations
of 92% and is tachypnoeic. Pulmonary
embolism was suspected and she was
organised for a chest X ray.

Which one of the following signs on the CXR
suggests acute pulmonary embolism?

1- Right heart enlargement

2- Prominent pulmonary vessels

3- Normal

4- Pleural effusion

5- Peripheral wedge shaped opacity

Answer & Comments

Answer: 5- Peripheral wedge shaped opacity

This question did not ask what was the most
common CXR finding in pulmonary embolism
which would make the best answer 'normal'.

There are two rare, signs which are Hampton's
hump and Westermark sign.

Hampton's hump is a radiologic sign seen on
chest radiographs indicating segmental
pulmonary infarction classically due to
pulmonary embolism. It consists of a pleura
based shallow wedge-shaped consolidation in

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the lung periphery with the base against the
pleural surface.

The Westermark Sign, is a sign that represents
a focus of oligemia (vasoconstriction) seen
distal to a pulmonary embolus.

The case scenario is consistent with primary
hyperparathyroidism.

PTH enhances active reabsorption of calcium
and magnesium from distal tubules and of the
kidney.

Right heart enlargement and prominent
pulmonary vessels are signs of chronic
pulmonary embolism rather than acute.

Hampton's hump in the right basal periphery

on this CXR

[ Q: 1821 ] MRCPass - 2010 January

A 25 year old woman presents with
lethargy, polyuria and nausea. She has no past
medical history and is currently not taking
medications. Her blood results are: sodium
135 mmol/l, potassium 4.3 mmol/l, urea 7
mmol/l, creatinine 90 pmol/l, calcium 3.2
(2.25-2.7) mmol/l, phosphate 0.3 (0.8-8)
pmol/l, Parathyroid hormone 18 (0.8-8)

pmol/l.

What is the likely couse of hypercalcaemia?

1- Hypocalciuric hypophosphataemic rickets

2- Chronic kidney disease

3- Hypophosphataemia

4- Parathyroid hormone excess

5- 1,25 (OH) vitamin D supplementation

As bone is degraded both calcium and
phosphate are released. It also greatly
increases the excretion of phosphate, with a
net loss in plasma phosphate concentration.
By increasing the calcium:phosphate ratio
more calcium is therefore free in the
circulation.

PTH enhances the absorption of calcium in the
intestine by increasing the production of
activated vitamin D. PTH up-regulates the
enzyme responsible for 1-alpha hydroxylation
of 25-hydroxy vitamin D, converting vitamin D
to its active form (1,25-dihydroxy vitamin D).

PTH stimulates bone resorption by
osteoclasts.

[ Q: 1822 ] MRCPass - 2010 January

A blood test has been used to assess
the likelihood of gastric cancer. The results are
as follows:

Cancer Diagnosed No Cancer
Positive 60 60
Negative 80 40

Whot is the positive predictive value?

1- 25%

2- 33.3%

3- 50%

4- 60%

5- 66.6%

Answer & Comments

Answer: 3- 50%

Answer & Comments

Answer: 4- Parathyroid hormone excess

The positive predictive value of a test is the
probability that the patient has the disease

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when restricted to those patients who test
positive.

This term is sometimes abbreviated as PPV.
You can compute the positive predictive value
as

PPV = TP/(TP + FP)

where TP and FP are the number of true
positive and false positive results,
respectively. In this case, the TP is 60, FP is 60
and PPV is 60/120 = 50%.

[ Q: 1823 ] MRCPass - 2010 January

A 35-year-old man is admitted with
left-sided pleuritic chest pains. These pains
have been occurring for the past 2 weeks.
Prior to the onset of the pains, he had been
experiencing flu-like symptoms.

What is the ECG most likely to show?

1- SI, Q3, T3

2- Atrial fibrillation

3- Widespread ST elevation

4- ST segment depression in the anterior leads

5- Tented T waves

Answer & Comments

Answer: 3- Widespread ST elevation

The diagnosis is likely to be pericarditis
(possibly viral aetiology) and classical ECG
changes of saddle shaped ST elevation are
expected

Widespread ST elevation on the ECG in

pericarditis

[ Q: 1824 ] MRCPass - 2010 January
Where is the site of action of thiazide

diuretics?

1- Proximal part of Distal Convoluted Tubule

2- Distal part of Distal Convoluted Tubule

3- Proximal convoluted tubule

4- Loop of Henle

5- Collecting ducts

Answer & Comments

Answer: 1- Proximal part of Distal Convoluted
Tubule

Thiazide diuretics reduce the reabsorption of
sodium and chloride in the early part of the
distal convoluted tubule of the kidney.

This results in the delivery of increased
amounts of sodium to the distal tubule, where
some of it is exchanged for potassium. The net
result is increased excretion of sodium,
potassium and water.

[ Q: 1825 ] MRCPass - 2010 January

A 23 year old male medical student
was brought to hospital by his girlfriend who
was concerned about his behaviour. He has
just returned from a student elective in the
United States. Whilst he was being assessed
he

appeared anxious and agitated. He was
restless and paced up and down the corridor.
He spoke very quickly.

Upon questioning, he said that he was doing
extremely well in medicine and soon was to
become the dean of the medical school.

What is the most likely diagnosis?

1- Paranoid chizophrenia

2- Anxiety disorder

3- Hypomania

4- Delusional disorder

5- Obsessive compulsive disorder

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Answer & Comments

[ Q: 1827 ] MRCPass - 2010 January

Answer: 3- Hvpomania

* 1 J

i y

A 43-year-old South Asian man had a

Hypomania is a mood state characterized by
persistent and pervasive elated or irritable
mood, and thoughts and behaviour that are
consistent with such a mood state.

routine blood test with his GP. He has no
symptoms. These results were found:

Hb 10.5 g/dl, MCV 75 fl, WCC 7 x 10 9 /l,
platelets 220 x 10 9 /l, HbA2 level 5% (<3.5%)

It is distinguished from mania by the absence
of psychotic symptoms and by its lower
degree of impact on functioning. Patients
often have pressured speech and grandiosity.

A blood film showed hypochromia, slight
microcytosis and anisocytosis, a few target
cells, and basophilic stippling.

What is the diagnosis?

There may be flight of ideas, lack of sleep and
inability to slow the mind down.

1- Sideroblastic anaemia

2- Alpha thalassemia trait

^ [ Q: 1826 ] MRCPass - 2010 January

ft -

# A 22-year-old man presents with
rectal bleeding and pain with opening his bow
els. He is prone to having periods

of constipation and notices that when he
cleans himself there is presence of blood on
the paper. Rectal

examination reveals no abnormality.

What is the most likely diagnosis?

1- Anal fissures

2- Anogenital herpes

3- Haemorrhoid

4- Rectal carcinoma

5- Rectal polyp

Answer & Comments

Answer: 1- Anal fissures

An anal fissure is a crack in the wall of the anal
mucosa so that the circular muscle layer is
exposed.

The peak incidence is in the 20-30 year old age
group. There is often a history of pain of
defaecation - often first occurs during a period
of constipation. There is also fresh rectal
bleeding at defaecation; the patient complains
of 'bright red blood on the paper'.

3- Beta thalassemia trait

4- Acute intermittent porphyria

5- Lead poisoning

Answer & Comments

Answer: 3- Beta thalassemia trait

The difficulty here is that both lead poisoning
and thalassemia trait, the blood film shows an
iron deficiency picture, target cells and
basophilic stippling.

As this patient is asymptomatic, it fits
thalassemia better. Below are descriptions of
some of the options.

thalassemia trait (minor): This trait is
characterized by mild anemia and low RBC
indices. This condition is typically caused by
the deletion of 2 ? (a) genes on one
chromosome 16 (aa/oo) or one from each
chromosome (ao/ao).

This condition is encountered mainly in
Southeast Asia, the Indian subcontinent.

thalassemia trait (minor): Patients have mild
anemia, abnormal RBC indices, and abnormal
Hb electrophoresis results with elevated levels
of Hb A2, Hb F, or both. Peripheral blood film
examination usually reveals marked
hypochromia and microcytosis (w ithout the
anisocytosis usually encountered in iron

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deficiency anemia), target cells, and faint
basophilic stippling. The production of a
chains from the abnormal allele varies from
complete absence to variable degrees of
deficiency.

Sideroblastic anemias: they usually associated
with microcytosis and hypochromia and thus
must be distinguished from the anaemia of
iron deficiency and thalassemia. A defect
causes iron to accumulate in mitochondria
ringing the red cell nucleus forming "ringed
sideroblasts". Most sideroblastic anaemia are
acquired and are associated with drugs
(alcohol*, isoniazid, chloramphenicol,
cytotoxic agents, and other Vit B6
antagonists), heavy metals (lead), and various
hematologic, neoplastic and inflammatory
diseases.

Lead poisoning: the anaemia is usually
microcytic; with basophilic stippling; ringed
sideroblasts; increased serum Fe, but may be
haemolytic. Symptoms include abdominal pain
with constipation; metabolic acidosis, and
may lead to shock, coma and death.

Ring sideroblast - iron accumulation in
mitochondria in red cells

polychrorrcfiia

4— _^

dimorphic

stippling ►

Basophilic stipling - due to denatured RNA in

the red blood cells

[ Q: 1828 ] MRCPass - 2010 January

A 42-year-old man has recently been
diagnosed with non-Hodgkin's lymphoma. He
has a long history of alcoholism and has
significant alcohol-related peripheral
neuropathy.

Which one of the following chemotherapy
agents should be avoided?

1- Chlorambucil

2- Cyclophosphamide

3- Epirubicin

4- Vincristine

5- Rituximab

Answer & Comments

Answer: 4- Vincristine

Vincristine (brand name, Oncovin), also known
as leurocristine, is a vinca alkaloid.

It works through disruption of the
microtubules which in turns disrupts
metaphase in mitosis. Its main uses are in
non-Hodgkin's lymphoma as part of the
chemotherapy regimen CHOP, Hodgkin's
lymphoma as part of MOPP, COPP, BEACOPP.

The main side-effects of vincristine are
peripheral neuropathy (which can be severe),
hyponatremia and hair loss.

[ Q: 1829 ] MRCPass - 2010 January

A 22-year-old man is investigated for
weight loss and abdominal pains. He also had
altered bow el habit with occational
diarrhoea. A rectal biopsy is taken and
reported as follows:

Deep inflammatory infiltrate from the mucosa
to the lamina propria

Numerous non caseating granulomata were
also seen.

What is the most likely diagnosis?

1- Crohn's disease

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2- Whipple's disease

3- Tuberculosis

4- Laxative abuse

5- Ulcerative colitis

Some of the infectious causes of bloody
diarrhoea are:

Salmonella

Shigella

Answer & Comments

Answer: 1- Crohn's disease

Microscopically, the classical changes seen
with Crohn's disease are non-caseating
granulomas, transmural inflammation and
lymphocyte infiltration.

The terminal ileum, caecum and rectum are
areas most commonly involved.

[ Q: 1830 ] MRCPass - 2010 January

A 32-year-old man who has returned
from a holiday in Egypt presents with
diarrhoea. For the past two days he has been
passing frequent bloody diarrhoea associated
with crampy abdominal pain. Abdominal
examination demonstrates diffuse lower
abdominal tenderness but there is no
guarding or rigidity. His temperature is 37.7°C.

Campylobacter jejuni
Yersinia enterocolitica
E. coli

Entamoeba histolytica

[ Q: 1831 ] MRCPass - 2010 January

Which one of the following is
implicated with a JAK2 mutation?

1- Multiple myeloma

2- Squamous cancer of the lung

3- Polycythaemia rubra vera

4- Haemophilia

5- Von Willebrand's disease

Answer & Comments

Answer: 3- Polycythaemia rubra vera

What is the most likely causative organism?

1- Giardiasis

2- Enterotoxigenic Escherichia coli

3- Staphylococcus aureus

4- Shigella

5- Salmonella

Answer & Comments

Answer: 4- Shigella

All are common causes of traveller's
diarrhoea.

However, North Africa and the Middle East (in
particular Egypt) were also commonly
reported regions of travel for Shigella spp
infections.

Janus kinase 2 (commonly called JAK2) is a
human protein that has been implicated in
signaling by members of the type II cytokine
receptor family.

These mutations have been associated with
polycythemia vera, essential

thrombocythemia, and other

myeloproliferative disorders.

[ Q: 1832 ] MRCPass - 2010 January

A 25 year old man has recently been
to India for a holiday, returning a week ago.
He presents with fatigue and abdominal pains.
He gives a history of diarrhoea for 5 days. On
examination, he was jaundiced and had
tender hepatomegaly. His investigations show:

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sodium 135 mmol/l, potassium 4.2 mmol/l,
urea 5 mmol/l, creatinine 100 pmol/l, ALT
1380 (5-35) U/l, AST 1430

(1-31) U/l, ALP 360 (20-120) U/l, GGT 320 (4-
35) U/l, Bilirubin 35 (1-22) pmol/l, Albumin 35
(37-49) g/l

What is the likely diagnosis?

1- HIV infection

2- Leptospirosis infection

3- Acute hepatitis A infection

4- Acute hepatitis B infection

5- Infectious mononucleosis

Answer & Comments

Answer: 3- Acute hepatitis A infection

The abrupt onset of fever, fatigue, malaise,
anorexia, nausea, diarrhea, jaundice and
abdominal discomfort are consistent with
acute hepatitis A infection (especially history
of diarrhoea).

Leptospirosis is less likely as there is no renal
involvement and infectious mononucleosis
does not usually cause diarrhoea.

[ Q: 1833 ] MRCPass - 2010 January

A 62-year-old man was diagnosed
with atrial fibrillation 3 weeks ago and started
on digoxin 125 meg od and warfarinised.
Despite this treatment he still feels his 'heart
race 1 regularly. An echocardiogram recently
done showed moderate left ventricular
dysfunction. On examination his pulse is 110 /
min, irregularly irregular and respiratory
examination is unremarkable.

What is the most appropriate next step in
management?

1- Switch digoxin for verapamil

2- Electrical cardioversion

5- Flecainide

Answer & Comments

Answer: 4- Add bisoprolol

It is difficult to tell if this patient has persistent
or permanent atrial fibrillation.

If he presents acutely and unwell, then
cardioversion (rhythm control) should be
considered. However, he has already gone
down the rate control route, and NICE
guidelines states that for patients not
controlled with monotherapy, a combination
of either beta blocker/calcium channel blocker
with digoxin should be given.

http://www.nice.org.uk/nicemedia/pdf/CG03

6niceguideline.pdf

[ Q: 1834 ] MRCPass - 2010 January

A 22 year old woman presents with
lethargy. She has no past medical history. She
takes only an oral contraceptive pill daily. On
examination, she has a slim build and a BMI of
23 and the only abnormality seen is dental
erosions. Her blood results show :

sodium 132 mmol/l, potassium 2.8 mmol/l,
urea 5 mmol/l, creatinine 100 pmol/l, AST 40
(1-31) U/l, ALP 150 (20-120)

U/l, Bilirubin 18 (1-22) |imol/l, Albumin 3 8(37-
49) g/l, calcium 2.0 (2.25-2.7) mmol/l,

phosphate 0.75 (0.8-8) pmol/l,

amylase 260 (60-180) U/l.

What is the diagnosis?

1- Bulimia nervosa

2- Crohn's disease

3- Laxative abuse

4- Diuretic use

5- Pregnancy

3- Add amiodarone

4- Add bisoprolol

Answer & Comments

Answer: 1- Bulimia nervosa

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Bulimia nervosa is most likely due to the
dental erosions.

Bulimia can produce a variety of metabolic
and electrolytic imbalances, especially when
combined with anorexia nervosa or

aggravated by the abuse of laxatives,

diuretics, thyroid hormone replacement
medications and cathartics. Less frequent

signs and symptoms include metabolic

alkalosis, low levels of serum protein, zinc
depletion, low levels of tryptophan and
serotonin, low levels of serum calcium and
chloride, high levels of alkaline phosphatase,
and high levels of serum amylase.

There is an increase in the total blood volume,
the plasma volume and the red cell volume
during pregnancy. The total blood volume
increases by about 30-40% by about 34 weeks
of pregnancy causing a haemodilution.
However, to produce such significant changes,
it would be a later stage of pregnancy the
diagnosis should then be obvious in this
patient.

^ [ Q: 1835 ] MRCPass - 2010 January

•Sf -

# A 18 year old man has presented for
investigation with haematuria. On his urine
dipstick, there were blood ++.

When enquired about family history, he said
his father and older brother also had
haematuria. An ANCA and ANA screen was
done with negative results. An ultrasound of
the kidney was normal and his creatinine was
80 umol/l.

Whot is the likely diagnosis?

1- Polyarteritis nodosa

2- Systemic lupus erythematosus

3- Alport's syndrome

4- Ig A nephropathy

5- Exercise induced haematuria

Answer & Comments

Answer: 3- Alport's syndrome

Alport's syndrome leads to a
glomerulonephritis.

It is a primary basement membrane disorder
arising from mutations in genes encoding
several members of the type IV collagen
protein family. The disease is mainly inherited
in the X linked form. In males, there is only
one X chromosome, so the disease tends to
manifest in males with the immediate family
as suggested above.

The clinical manifestations include recurrent
episodes of gross hematuria, especially in
childhood, as in the case vignette.
Hypertension, proteinuria and sensorineural
hearing loss can take place although those
clues were not given in this scenario.

^ [ Q: 1836 ] MRCPass - 2010 January

f§ -

0 You are performing a study of blood
pressure readings in patients with chronic
kidney disease. Assuming that the results are
normally distributed, whot percentage of
values lies above two standard deviations of
the mean reading?

1- 2.5

2- 5

3- 10

4- 95.4

5- 99.7

Answer & Comments

Answer: 1- 2.5

The question has to be read cautiously.

In this question regarding 2 standard
deviations, 95% of patients will lie within 2 SD
and 2.5% of patients will lie above 2 SD and
2.5% of patients will lie below 2 SD.

•68.3% of values lie within 1 SD of the mean

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•95.4% of values lie within 2 SD of the mean
•99.7% of values lie within 3 SD of the mean

[ Q: 1837 ] MRCPass - 2010 January

A 47-year-old man with habitual
smoking habit (2 packs per day) presents with
haemoptysis. He also suffered had poor
appetite for 6 months and body weight loss
(loss 6 kilograms). His blood results are:

Hb 11.5 g/dl, MCV 75 fl, WCC 6 x 10 9 /l,
platelets 200 x 10 9 /l, sodium 125 mmol/I,
potassium 4.5 mmol/I, urea 5 mmol/l,
creatinine 100 |imol/l.

Which one of the following is the most likely
lung cancer in this patient?

1- Squamous cell

2- Small cell

3- Adenocarcinoma

4- Large cell

5- Carcinoid

Answer & Comments

Answer: 2- Small cell

Small-cell lung cancer accounts for
approximately 20-25% of all cases of lung
cancer.

It is strongly associated with smoking. Small
cell carcinomas produce ACTH and ADH, which
can lead to SIADH, the clue in the history is
hyponatraemia.

[ Q: 1838 ] MRCPass - 2010 January

A 19 year-old man presents with
facial and ankle sw elling which has slow ly
been developing over the past 2 weeks. A
urine dipstick shows protein ++++.

What is the most likely cause of this
presentation?

1- IgA nephropathy

2- Focal segmental glomerulonephritis

3- Minimal change disease

4- Membranous glomerulonephritis

5- Renal cell carcinoma

Answer & Comments

Answer: 4- Membranous glomerulonephritis

With no haematuria, IgA nephropathy is
unlikely.

The most likely options are minimal change
and membranous. Due to the age of
presentation, membranous

glomerulonephritis is the best answer.

Minimal change nephropathy is responsible
for 90% of the cases of nephrotic syndrome in
children less than 5 years of age. The name is
due to the fact that the only detectable
abnormality histologically is fusion and
deformity of the foot processes under the
electron microscope. It also occurs in adults -
approx 20%. Normal renal function and blood
pressure are typical.

Membranous glomerulonephritis often
presents with nephrotic syndrome in males. It
is characterized histologically by thickening of
the capillary basement membrane secondary
to the deposition of immune complexes. It is
associated with SLE, drugs and malignancy.
About 33% of patients affected go into
spontaneous remission over five years, but
the remainder are likely to develop
progressive renal failure Focal segmental
glomerulonephritis is a possibility for

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nephrotic presentation but is often associated
with HIV and malignancy, and less common.

Answer & Comments

Answer: 2- IV benzylpenicillin + gentamicin

^ [ Q: 1839 ] MRCPass - 2010 January

n -

# A 35 year old woman who is on
several different medications has developed
alopecia.

Which one of the following drugs is likely to
couse this?

1- Methyldopa

2- Sodium valproate

3- Phenytoin

4- Metoclopramide

5- Minoxidil

Answer & Comments

Answer: 2- Sodium valproate

Dyspepsia, weight gain and alopecia are side
effects of sodium valproate

[ Q: 1840 ] MRCPass - 2010 January

A 70-year-old man is admitted to the
hospital with fevers, lethargy and night
sweats.

He has a history of diabetes and had a
prosthetic mitral valve replacement 5 years
ago. An echocardiogram is arranged which
shows a vegetation around the prosthetic
mitral valve. 3 sets of blood cultures were
taken and 4/6 of the bottle grew alpha
haemolytic streptococci, a day later.

Alpha haemolytic streptococci suggests strep
viridans.

Acute endocarditis is most commonly caused
by staph aureus, whilst subacute endocarditis
(often with prosthetic valves) is most
commonly caused by strep viridans.

Standard therapy to start with (until cultures
are know n) is intravenous benzylpenicillin and
gentamicin unless staphylococcal is suspected
or if there is penicillin allergy when
vancomycin is substituted for penicillin.

For strep viridans infection treatment is for 2
weeks with benzylpenicillin and gentamicin.

[ Q: 1841 ] MRCPass - 2010 January

A 25year-old male athlete suffered
cardiac arrest while playing football. He was
resuscitated on the field but passed aw ay on
the way to hospital. The patient had
previously noticed an "irregular heart beat" on
several occasions but no chest pain. He had no
family history of cardiac arrhythmia or sudden
death.

Whot is the most likely couse of death?

1- Arrhythmogenic right ventricular
cardiomyopathy

2- Brugada syndrome

3- Massive pulmonary embolus

4- Hypertrophic cardiomyopathy

Whot is the most appropriate antibiotic
therapy?

1- IV benzylpenicillin + vancomycin

2- IV benzylpenicillin + gentamicin

3- IV ceftriaxone + benzylpenicillin

4- IV flucloxacillin + gentamicin

5- IV vancomycin + gentamicin + rifampicin

5- Diabetic ketoacidosis

Answer & Comments

Answer: 4- Hypertrophic cardiomyopathy

Although all are possibilities, under the age of
35, the most common cause of sudden death
among athletes is hypertrophic
cardiomyopathy.

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In hypertrophic cardiomyopathy, there is a
thickened cardiac muscle, no evidence of
chamber enlargement, and extensive
myocardial scarring.

Athletes with hypertrophic cardiomyopathy
have an increased frequency of ventricular
arrhythmia (a disturbance in the rhythm of the
heartbeat). In these cases, the cardiac
enlargement is concentric (symmetric) and
there is no evidence of obstruction of the
outflow tract in the left ventricle. Athletes
with this condition often complain of cardiac
palpitation or cardiac flutter and may have
syncopal or fainting episodes, in which the
athlete collapses after a strenuous workout.

[ Q: 1842 ] MRCPass - 2010 January

A 55-year-old man with many years
of type 2 diabetes and multiple complications
presents complaining of occasional episodes
of green/blue vision. He is taking many
medications, which is the likely drug causing
this?

1- Phenytoin

2- Lithium

3- Metformin

4^ [ Q: 1843 ] MRCPass - 2010 January

# A 35 year old man has presented
with back pains and joint pains over several
months. He has no other past medical history
to date. He mentioned that his father had a
history of joint problems. On examination,
there is no evidence of skin involvement. Joint
examination revealed evidence of synovitis in
the metacarpophalangeal, metatarsal and
wrist joints bilaterally limiting his range of
joint movements.

Laboratory testing revealed a C-reactive
protein of 0.33 mg/dl (<0.80 mg/dl), strong
positive CCP antibody, IgG of 148 Units (<20
Units), and angiotensin-converting-enzyme
(ACE) of 73 U/liter (<67 U/liter). Anti nuclear
antibody (ANA), anti neutrophil cytoplasmic
antibody (ANCA) and rheumatoid factor (Rh F)
were negative.

What it the diagnosis?

1- Dermatomyositis

2- Psoriatic arthropathy

3- Rheumatoid arthritis

4- Osteoarthritis

5- Systemic lupus erythematosus

4- Cisapride

5- Sildenafil

Answer & Comments

Answer: 3- Rheumatoid arthritis

Answer & Comments

Answer: 5- Sildenafil

Sildenafil (Viagra) is a phoshodiesterase
inhibitor used for erectile dysfunction.

The principal side-effects include dyspepsia,
flushing and dizziness. The green/blue tint to
vision is more common at the higher doses -
and it might make it easy to remember as the
pills are blue. The retina contains
phosphodiesterase and inhibition of this is
thought to be responsible for this
phenomenon.

Anti-citrullinated protein/peptide antibodies
(Anti-CCP) are autoantibodies frequently
detected in rheumatoid arthritis patients.

It has a sensitivity of 70% as a diagnostic test.
The positive anti-CCP antibodies and
symmetrical polyarthropathy without skin
involvement suggests rheumatoid arthritis.

Rheumatoid factor is an IgM antibody against
IgG. Some patients with rheumatoid arthritis
will have a negative rheumatoid factor, as in
this case.

•I J

[ Q: 1844 ] MRCPass - 2010 January

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A patient has developed facial swelling
following treatment with an ACE inhibitor. In
patients with angioedema, which chemical
mediator is mainly reponsible for causing
vascular permeability and the tissue oedema?

1- Histamine

2- Serotonin

3- Neurokinin A

4- Bradykinin

5- Nitric oxide

Answer & Comments

Answer: 4- Bradykinin

5- Thrombolysis

Answer & Comments

Answer: 4- DC cardioversion

This patient is symptomatic and unstable with
hypotension, DC cardioversion is the best
option as it will restore sinus rhythm and
allow the patient a good chance of recovery.

Amiodarone is a good option, but this scenario
of unstable patient suggests DC cardioversion
is quicker. As verapamil and bisoprolol are
negatively inotropic, they are contraindicated
due to the hypotension.

Bradykinin is a vasoactive nonapeptide
produced by the kinin system.

It causes vasodilation, possibly by a direct
effect and via prostaglandin mediation. It also
causes an increase in vascular permeability by
the opening of intercellular gaps in post¬
capillary venules. Bradykinin is inactivated by
angiotensin converting enzyme, hence ACE
inhibitors are often associated with
angioedema.

[ Q: 1846 ] MRCPass - 2010 January

Which one of these conditions is
associated with Human Herpes Virus (HHV) 8
infection?

1- Chicken pox

2- Malignant melanoma

3- Genital warts

4- Kaposi's sarcoma

5- Shingles

[ Q: 1845 ] MRCPass - 2010 January

A 82 year old man is admitted with
palpitations, dizziness and shortness of
breath. He has a history of hypertension and
diabetes. His current medications are
bendroflumethiazide and metformin. He has
an ECG which showed atrial fibrillation with a
heart rate of 150 bpm. On examination, he
has a BP of 80/45 mmHg and JVP is raised. His
heart sounds are normal and there are a few
crackles in the bases of the lungs.

Which of the following is the best
management?

1- IV verapamil

2- IV Amiodarone

3- IV Bisoprolol

4- DC cardioversion

Answer & Comments

Answer: 4- Kaposi's sarcoma

HHV 8 is associated with co-infection with HIV
and Kaposi's sarcoma.

Genital warts are caused by Human Papilloma
virus. Chicken pox is caused by varicella zoster
virus Shingles is caused by latent reactivation
of the varicella zoster virus within a nerve.

[ Q: 1847 ] MRCPass - 2010 January

A 33-year-old Caucasian woman
admitted has a history of widespread, pruritic,
erythematous skin rash, joint pains and renal
disease. She recently had a baby with
congenital heart block. Laboratory
investigations revealed mild leucopenia (w

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hite cell count 3.25xl09/ml) and
thrombocytopenia (platelets 140xl09/ml).
Erythrocyte sedimention rate was increased
(65 mm/h).

Which antibody is likely to be positive?

1- Anti Jo 1

2- Anti double stranded DNA

Whot is the most likely diagnosis?

1- Amyotrophic lateral sclerosis

2- Multiple sclerosis

3- Progressive muscular atrophy

4- Subacute combined degeneration

5- Syringomyelia

3- Anti Ro

4- Anti centromere

5- ANCA

Answer & Comments

Answer: 3- Anti Ro

The anti Ro antibody is associated with
Sjogren's syndrome, SLE and neonatal lupus.

Neonatal lupus erythematosus (NLE) is a rare
disorder caused by the transplacental passage
of maternal autoantibodies. Only 1% of infants
with positive maternal autoantibodies develop
neonatal lupus erythematosus. The most
common clinical manifestations are cardiac
(congenital heart block), dermatologic
(urticaria and skin desquamation), and hepatic
(abnormal LFTs). The mother produces
immunoglobulin G (IgG) autoantibodies
against Ro (SSA), La (SSB), and/or Ul-
ribonucleoprotein (Ul-RNP), and they are
passively transported across the placenta.
These autoantibodies can be found alone or in
combination; However, anti-Ro is present in
almost 95% of patients.

[ Q: 1848 ] MRCPass - 2010 January

A 64-year-old man presents with a
eight-month history of generalised weakness.
He has no previous past medical history but
his father had a history of a similar illness at
the age of 78. On examination he has
fasciculation and weakness in both arms with
absent reflexes. Examination of the lower
limbs reveal increased tone and brisk reflexes
with upgoing plantars. There was no sensory
deficit.

Answer & Comments

Answer: 1- Amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis is a form of
motor neurone disease (MND).

It is the most common form of MND and
accounts for 65% to 85% of all cases of MND.
It is typically late onset, rapidly progressive
and presents with a combination of upper and
lower motor neuron signs.

Three main types of MND are recognised and
most patients eventually develop features of
all three:

progressive muscular atrophy
amyotrophic lateral sclerosis
bulbar palsy

[ Q: 1849 ] MRCPass - 2010 January

A 65-year-old female is admitted to
the Emergency Department following an
overdose of a long-acting atenolol
preparation. On admission she is bradycardic
with a pulse of 35/min and BP 90/50 mmHg.
The bradycardia fails to respond to 3 doses of
1 mg of atropine.

What is the next most appropriate

management?

1- Temporary cardiac pacing

2- Calcitonin

3- Glucagon

4- Noradrenaline infusion

5- Salbutamol infusion

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Answer & Comments

Answer: 3- Glucagon

Glucagon stimulates production of cAMP
through nonadrenergic pathw ays and can be
given early in beta blocker poisoning.

A dose of 3-10 mg IV bolus followed by 2-5
mg/h infusion should be commenced. Cardiac
pacing should be reserved for patients
unresponsive to pharmacologic therapy or for
those with torsade de pointes unresponsive to
magnesium.

themselves, but rather the fear or idea of
having a serious disease. The fear or idea is
based on the misinterpretation of bodily signs
and sensations as evidence of disease.

Somatisation disorder: (somatoform disorder)
With this a patient presents with multiple,
medically unexplained symptoms. The
patient's life or work are frequently affected,
although they also might be unconcerned
about the nature of their symptoms (thus
appearing calm). It is not a deliberate feigning
of symptoms.

[ Q: 1850 ] MRCPass - 2010 January

A 35 year old man was investigated
for palpitations. He was told that he had
premature ventricular complexes on the ECG.
However, he was convinced that he had
cancer and presented to the surgery many
times over the year despite reassurance.

Whot is the diagnosis?

1- Munchausen's syndrome

2- Hypochondriasis

3- Dissociative disorder

4- Somatisation disorder

5- Conversion disorder

Answer & Comments

Answer: 2- Hypochondriasis

Conversion disorder : (somatoform

[ Q: 1851 ] MRCPass - 2010 January

A 45-year-old woman presents with
weight gain and recurrent 'dizzy' episodes.
Over the past four months she has gained 15
kg. The episodes occur on an almost daily
basis and are characterised by blurred vision,
sweating and headaches. Her GP checked a
blood sugar during one of these episodes
which was record as being 2.0 mmol/l.

What is the single most useful test if the
patient presents with a further such episode?

The history fits a diagnosis of hypochondriasis
as below Munchausen syndrome (factitious
disorder): the patient seeks medical attention
by the deliberate production or feigning of
symptoms.

The motivation for seeking attention is not
known.

1- Glucagon level

2- Plasma glucose

3- Insulin + C-peptide levels

4- Sulphonylurea level

5- Thyroid function

Answer & Comments

Answer: 3- Insulin + C-peptide levels

The ideal measurement is glucose, insulin and
C peptide levels.

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This is not given as an option, and neither is a
72 hour fast. Only an insulin and C peptide
level (which are elevated during one of these
episodes) will confirm the diagnosis of a
possible insulinoma (pancreatic insulin
secreting tumour as suggested in the clinical
history).

A 72-hour fast, usually supervised in a hospital
setting, can be done to see if insulin levels fail
to suppress during a hypoglycaemic episode
(glucose <2.5 mmol/l). The C peptide levels as
proinsulin is broken down to insulin and C
peptide. If present, then the patient is unlikely
to be injecting insulin exogenously.

Since drugs are approved on the basis of
clinical trials which involve relatively small
numbers of people who have been selected
for this purpose, postmarketing surveillance
can further refine the safety of a drug after it
is used in the general population by large
numbers of people who have a wide variety of
medical conditions.

Postmarketing surveillance uses a number of
approaches to monitor the safety of licensed
drugs, including spontaneous reporting
databases, prescription event monitoring,
electronic health records, patient registries
and record linkage between health databases.

[ Q: 1852 ] MRCPass - 2010 January

A new drug which has been on the
market for 2 years, has had reports of possible
serious side effects of fulminant hepatitis.

What is the best way of evaluate this from a
safety perspective?

1- Metanalysis

2- Postmarketing surveillance

[ Q: 1853 ] MRCPass - 2010 January

A 42-year-old male developed neck
pain which had worsened over several years.
He presented to a rheumatologist with weight
loss, back pain and stiffness. Clinical
examination showed very restricted neck
movement and chest expansion with no
lumbar spinal movement. X rays of the
patient's spine were performed.

3- Randomised controlled trial

4- Systematic review

5- Case control study

Answer & Comments

Answer: 2- Postmarketing surveillance

New drugs which have had regulatory
approval may not have trial data which
contain enough information about rare,
serious side effects, and there may not be
sufficiently large trials for a new drug for
metanalysis.

Postmarketing surveillance (PMS) is the
practice of monitoring the safety of a
pharmaceutical drug after it has been released
on the market and is an important part of the
science of pharmacovigilance.

What feature would be expected on the x rays
in ankylosing spondylitis?

1- Sclerosis

2- Syndesmophyte

3- Lytic lesions

4- Osteophyte

5- Wedge shaped lesions

Answer & Comments

Answer: 2- Syndesmophyte

Typical X ray changes of ankylosing spondylitis
are the visible formation of syndesmophytes
(bony growth originating inside a ligament)
and abnormal bone outgrow ths similar to
osteophytes affecting the spine.

These changes lead to an appearance of
'bamboo spine'.

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This lady has oligomenorrhoea with evidence
of hyperandrogenism and the most likely
cause is polycystic ovarian syndrome (PCOS),
which is characterised by hyperandrogenism.

In the complete syndrome, adipose tissue
aromatise peripheral androgens to
oestrogens. This suppresses FSH thus reducing
follicullar maturation and fertility, as well as
increases LH resulting in further androgen
synthesis. Increased androgens results in
hirsutism and acne and also maintain the cycle
of peripheral aromatisation to maintain
elevated oestrogen levels. An elevated LH:FSH
ratio of greater than 3 is useful in confirming
the diagnosis of PCOS but its absence does not
exclude it.

Syndesmophyte

[ Q: 1854 ] MRCPass - 2010 January

# A 40-year-old woman is referred by
her GP with a history of oligomenorrhoea. In
clinic, the patient also describes acne as well
as hirsutism, such that she has to shave
around her chin and lip region every week.
Her body mass

index is 35 Kg/m2 and Blood pressure was 170
/ 95 mmHg. The following blood results were
obtained:

Her fasting blood glucose is 6.8mmol/l.

testosterone 7 (1.1-6.3) pg/ml

LH 16 (0.5-14.5) U/l

FSH 2.8(1-11) U/l

What is the most likely diagnosis?

1- Congenital adrenal hyperplasia

2- Cushing's syndrome

3- Conn's syndrome

4- Polycystic ovarian syndrome

5- Uterine fibroids

[ Q: 1855 ] MRCPass - 2010 January

A 17-year-old man presented
casualty complaining of difficulty breathing.
He had brought hospital by ambulance, having
collapsed shortly after being stung on hand by
a bee. On examination, his blood pressure was
80/40 mmHg, facial sw elling and pharyngeal
oedema was noted.

Which one of following investigations likely
confirm anaphylaxis?

1- Haemolytic complement (CH50) level

2- Plasma tryptase activity

3- Complement C3 level

4- Total IgE level

5- Eosinophil count

Answer & Comments

Answer: 2- Plasma tryptase activity

The reaction involves preferential production
of IgE, in response certain antigens, which in
turn initiates a sequence of events leading to
mast cell activation.

Answer & Comments

Answer: 4- Polycystic ovarian syndrome

According to the Resuscitation council
guidelines, the specific test to help confirm a

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diagnosis of an anaphylactic reaction is
measurement of mast cell tryptase.

Tryptase is the major protein component of
mast cell secretory granules. In anaphylaxis,
mast cell degranulation leads to markedly
increased blood tryptase concentrations.
Tryptase levels are useful in the follow -up of
suspected anaphylactic reactions, not in the
initial recognition and treatment: measuring
tryptase levels must not delay initial
resuscitation. Tryptase concentrations in the
blood may not increase significantly until 30
minutes or more after the onset of symptoms,
and peak 1-2 hours after onset.

The half-life of tryptase is short
(approximately 2 hours), and concentrations
may be back to normal within 6-8 hours, so
timing of any blood samples is very important.

http://www .resus.org.uk/pages/reaction.pdf

[ Q: 1856 ] MRCPass - 2010 January

A 35 year old man presented with a
generalised seizure. On examination, he was
found to have adenoma sebaceum on the
face, two hypopigmented areas and
subungual fibroma. He had a urine dipstick
showing blood ++ and was organised to have
an ultrasound of the kidneys which showed
cystic changes.

Whot is the likely diagnosis?

1- Von Hippel Lindau

2- Neurofibromatosis

3- Vitiligo

4- Acromegaly

5- Tuberous sclerosis

Answer & Comments

Answer: 5- Tuberous sclerosis

The diagnosis is tuberous sclerosis.

It is an autosomal dominant condition.
Features are epilepsy (cortical tubers in the

brain), adenoma sebaceum on the skin,
subungual fibroma of the nails, oval
hypopigmented macules - ash leaf macules -
best seen with Wood's (UV) light, retina
phakoma, renal angiomyolipoma (causing
cystic renal lesions) and cardiac
rhabdomyomas.

[ Q: 1857 ] MRCPass - 2010 January

A patient presents with an inability
to abduct his right shoulder.

Which nerve supplies this muscle?

1- Lateral cutaneous

2- Suprascapular

3- Musculocutaneous

4- Axillary

5- Median

Answer & Comments

Answer: 4- Axillary

The deltoid muscle is implicated here, as the
action is shoulder abduction.

It is innervated by the axillary nerve (C5 and
C6).

[ Q: 1858 ] MRCPass - 2010 January

A set of parents is seeking genetic
They said that their 5-year-old boy
with cystic fibrosis but they themselves do not
have the disease. They also have a daughter
who is 17 years old but not affected by the
disease.

Whot is the chance that she will be a carrier of
the cystic fibrosis gene?

1- 1 in 2

2- 1 in 4

3- 2 in 3

4- 1 in 25

5- 100% chance

advice.

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Answer & Comments

Answer: 3- 2 in 3

Inheritance of cystic fibrosis is autosomal
recessive.

In answering this question, the simple mistake
is to take carriers out of total, which makes a 1
in 2 chance. The diagram below illustrates the
best way of working this out.

As the daughter is not affected, there are 3
other options, so she might be a carrier in 2 of
the 3 scenarios (2 in 3).

[ Q: 1859 ] MRCPass - 2010 January

# A 45 year old lady presented to her
GP with lesions in skin that were circular with
an erythematous raised rim with central
atrophy. There was scaliness, follicular
plugging, and telangiectasia over the scalp,
ears and face.

This was confirmed to be discoid lupus by the
dermatologist and she has been tried on
betnovate steroid topical treatment but has
not improved.

What should be used next?

Hydroxychloroquine is the gold standard
treatment. Other options include
azathioprine, dapsone, thalidomide and
tacrolimus.

[ Q: 1860 ] MRCPass - 2010 January

A 44 year old type I diabetic is
referred for renal investigations. She has been
diagnosed with multiple myeloma 5 years ago.
She is currently on chemotherapy. She had
proteinuria on a urine dipstick 4+ and
quantification with 24 hour urine collection
revealed that she had urinary protein 3.5
g/day. Ultrasound of the abdomen shows
increased renal echogenicity. Investigations
show :

Hb 11.5 g/dl

MCV 82 fl

WCC 12 x 10 9 /l

platelets 225 x 10 9 /l

sodium 135 mmol/l

potassium 4.5 mmol/l

Urea 16 mmol/l

Creat 225 umol/l

1- Diprobase cream

2- Tacrolimus

3- Azathioprine

4- Hydroxychloroquine

5- PUVA therapy

Answer & Comments

Answer: 4- Hydroxychloroquine

Discoid lupus erythematosus (DLE) is a
chronic, scarring, atrophy producing,
photosensitive dermatosis.

DLE may occur in patients with systemic lupus
erythematosus (SLE).

Initial treatment comprises the avoidance of
direct sunlight. Following this,

Whot is the probable diagnosis?

1- Minimal change glomerulonephritis

2- Diabetic nephropathy

3- NSAIDS induced nephropathy

4- AL amyloidosis

5- Crescentic glomerulonephritis

Answer & Comments

Answer: 4- AL amyloidosis

Amyloidosis is a clinical disorder caused by
extracellular and or intracellular deposition of
insoluble abnormal amyloid fibrils that alter
the normal function of tissues.

AL amyloidosis can be caused by multiple
myeloma and occurs in 5 to 15% of such
patients. Apart from nephrotic syndrome,

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cardiomyopathy, polyneuropathy and gut
involvement are common presentations with
AL amyloid.

^ [ Q: 1861 ] MRCPass - 2010 January

# A 68-year-old woman presents with
a two month history of electric shock like
pains on the right side of her face and jaw .
She describes having several episodes a day
which, each lasting for several minutes up to 2
hours. A recent dental check was normal.
Neurological examination is unremarkable.

What is the most suitable medication for
prophylaxis ?

1- Amitriptyline

2- Sodium valproate

3- Carbamazepine

4- Phenytoin

5- Gabapentin

Answer & Comments

Answer: 3- Carbamazepine

The clinical history is typical for trigeminal
neuralgia.

[ Q: 1862 ] MRCPass - 2010 January

A 45 year old lady has had a renal transplant 2
weeks ago. She is complaining of fevers,
lethargy and diarrhea 3-4 times a day. She is
on the following medications: cyclosporine A
250mg bd, azathioprine 75mg od and
prednisolone 20mg od.

On examination, she has a blood pressure of
115 / 75 mmHg and a temperature of 37.8 C.
Her abdomen is soft and the area over the
renal transplant is mildly tender. The urine
output is normal. An ultrasound scan of the

kidneys does not show any abnormality that
points tow ards the cause.

Results show :

Hb 11.5 g/dl,

WCC11 x 10 9 /l,

platelets 230 x 10 9 /l

sodium 135 mmol/l

potassium 4.5 mmol/l

urea 7 mmol/l

creatinine 110 mmol/l (90 immediately post
transplant)

Urine dipstick : protein -

Carbamazepine is regarded by most as the
medical treatment of choice. The American
Academy of Neurology published a practice
parameter that concluded that carbamazepine
is effective in controlling pain of patients with
classic trigeminal neuralgia, and that
oxcarbazepine is probably effective. Baclofen,
lamotrigine, and pimozide were rated as
possibly effective. The practice parameter
stated that there was insufficient evidence to
support or refute efficacy of clonazepam,
gabapentin, phenytoin, tizanidine, topical
capsaicin, or valproate for pain control in
patients with classic trigeminal
neuralgia

J
y

Blood +

What is the likely cause of this presentation?

1- Allopurinol toxicity

2- Coronary artery disease

3- Cyclosporin toxicity

4- CMV infection

5- Acute rejection

Answer & Comments

Answer: 4- CMV infection

CMV infection is a multifaceted phenomenon
with a variety of direct and indirect effects in
the organ transplant recipient.

The symptomatology for clinical infectious
disease (ie, fever, pneumonia, Gl ulcers,

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hepatitis) ranges from the mild, subclinical
case to life-threatening multi-organ disease.
Most cases of symptomatic CMV infection can
be characterized by a self-limiting syndrome
of episodic fever spikes for a period of 3 to 4
weeks, arthralgias, fatigue, anorexia,
abdominal pain, and diarrhoea. Ganciclovir is
the most commonly used agent for the
prevention of CMV infection.

Acute rejection is usually associated with a
rise in creatinine and tenderness over the
transplant graft. In this case, the systemic
symptoms suggest that CMV infection is more
likely than acute rejection. Cyclosporin toxicity
is also unlikely as the creatinine and
potassium are not significantly changed.

[ Q: 1863 ] MRCPass - 2010 January

Which one of the following factors is
most useful os o predictor for determining the
risk of sudden death in a patient with
hypertrophic cardiomyopathy?

1- Family history of sudden death

2- Left ventricular outflow gradient > 30mmHg

3- Ejection fraction

4- Blood pressure volatility on physical
exertion

[ Q: 1864 ] MRCPass - 2010 January

A 42-year-old woman is brought to
the hospital by her husband. He

reports that she has had an argument with
their son which resulted in the son running aw
ay. Since the event, she has been very
stressed and suddenly has stopped talking
completely. Clinical examination of her throat
and chest is unremarkable.

Which one of the following terms best
describes this presentation?

1- Akinetic mutism

2- Depression

3- Expressive dysphasia

4- Schizophasia

5- Psychogenic aphonia

Answer & Comments

Answer: 5- Psychogenic aphonia

The two most likely answers are either
akinetic mutism or psychogenic aphonia.

Psychogenic aphonia or aphasia, is the loss of
language due to a non-organic or psychiatric
cause. It is the more likely answer due to the
stressful event precipitating aphonia.

5- Septal wall thickness > 3.0 cm

Answer & Comments

Answer: 5- Septal wall thickness > 3.0 cm

Non-sustained ventricular tachycardia,
syncope, abnormal blood pressure response
to exercise, family history of sudden death,
and massive left ventricular (LV) hypertrophy
are all risk factors for sudden death in
hypertrophic cardiomyopathy.

However, septal wall thickness is the most
important predictor of sudden death. The
greater thickness of septum, more likely there
is risk of cardiac arrhythmias (> 3 cm is
significant).

Akinetic mutism is a variety of stupor in which
the patient is unable to talk or carry out
purposeful behaviour but may

lie with eyes open, seemingly unaw are of
what is going on. It results from bilateral
damage to the orbital surface of the frontal
lobes, such as anterior cerebral artery stroke.
The patient appears awake and has normal
ocular movement but does not speak and has
minimal motor response to painful
stimulation. It can be associated with anterior
cerebral artery stroke.

[ Q: 1865 ] MRCPass - 2010 January

A 75 year-old female was seen in the
Emergency department with a 2 day history of

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headaches and fever. On examination, the
patient had a temperature of 38.5 °C. There
was also evidence of meningism with a
positive Kernig's sign. Tone, power and
reflexes were normal apart from general
weakness. There was no sensory deficit. A
lumbar puncture was performed. CSF showed
100 white cells (90% lymphocytes), protein 0.9
(<0.5) and glucose 3.3, plasma glucose 7.5.

Whot is the diagnosis?

1- Gullain barre syndrome

2- Listeria meningitis

3- Tuberculous meningitis

4- Poliomyelitis

5- HSV encephalitis

3- Eastern blotting

4- Western blotting

5- Polymerase chain reaction

Answer & Comments

Answer: 1- Northern blotting

The northern blot is a technique used in
molecular biology research to study gene
expression by detection of RNA in a sample.

Northern blotting involves the use of
electrophoresis to separate RNA samples by
size, and detection with a hybridization probe
(either DNA or RNA) complementary to part
gene sequence.

Answer & Comments

Answer: 3- Tuberculous meningitis

In Tuberculous meningitis, Fever, headache,
confusion and meningism are presenting
features.

Meningism is absent in a fifth of patients with
TB meningitis.

The CSF usually has a high protein, low glucose
and a raised number of lymphocytes as seen
in this patient.

Acid-fast bacilli are sometimes seen on a CSF
smear, but more commonly, M. tuberculosis is
grown in culture.

^ [ Q: 1867 ] MRCPass - 2010 January

A -

* A 42 year old woman presents with
breathlessness. She has a history of
pulmonary fibrosis associated with connective
tissue disease. Her lung function tests show :

FVC (I) (% predicted) 2.28 (66%)

FEV1 (I) (% predicted) 2.04 (70%)

FEV1/FVC (%) 89

total lung capacity (TLC) = 2.9 L (70%)

TLCO mmol/kPa/min (% predicted) 8.5 (110)
KCO mmol/kPa/min/l (% predicted) 4.4 (150)
What is the diagnosis?

1- Pulmonary haemorrhage

In this patient, HSV is unlikely as the protein is
high, and listeria should cause a picture with
more polymorphonuclear white cells in the
CSF

[ Q: 1866 ] MRCPass - 2010 January

Which one of the following
technigues is used to detect RNA using a
labelled DNA probe for hybridisation?

1- Northern blotting

2- Southern blotting

2- Pulmonary embolism

3- Pleural effusion

4- Emphysema

5- Diaphragmatic weakness

Answer & Comments

Answer: 1- Pulmonary haemorrhage

The lung function shows a restrictive picture,
reduced FEV1 and FVC, which are consistent
with the underlying connective tissue disease.

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However, as well as a slightly increased TLCO,
there is significantly increased KCO (transfer
factor) which suggests pulmonary
haemorrhage.

Transfer factor for carbon monoxide (TLCO) is
a useful investigation in alveolar
haemorrhage. It is actually the product of
alveolar volume and carbon monoxide
transfer coefficient (KCO). The alveolar
volume is mildly reduced because of alveolar
filling with blood, and KCO is considerably
increased because the inhaled CO reacts with
extravascular haemoglobin. An increased
TLCO with considerably increased KCO and
mildly reduced alveolar volume are
characteristic of pulmonary haemorrhage.

^ [ Q: 1868 ] MRCPass - 2010 January

a -

m A 22 old student nurse complained
of severe itching and sw elling in the hands,
several minutes after wearing gloves. This has
occurred before 10 years ago when he first
put a set of gloves on. On examination, there
was a flexural rash and sw elling in the hands.

1/1 /hot is the diagnosis?

1- Contact dermatitis

2- Systemic lupus erythematosus

3- Cl esterase inhibitor deficiency

4- Latex allergy

5- Anaphylaxis

Answer & Comments

Answer: 4- Latex allergy

The quick reaction in this case suggests latex
allergy, whilst in contact dermatitis the skin
changes will be slower to develop.

An allergy to latex (the natural rubber latex
protein in rubber) is an immediate
hypersensitivity (IgE mediated) reaction.

This means that the speed of onset of features
of a latex allergy occur over a short period of

time (seconds+ (up to 6 hours)).
Dermatological manifestations include itching,
burning skin and urticaria. There may be
associated angioedema and even anaphylaxis
(with bronchospasm or hypotension).

There are two types of contact dermatitis :
allergic and irritant. Allergic contact dermatitis
requires prior sensitization of the skin to a
specific allergen. T lymphocytes become
specially sensitised to the allergen, leading to
a dermatitis reaction. It is an example of a
type IV hypersensitivity reaction. Irritant
contact dermatitis is a result of direct damage
to the skin by the provoking agent. No prior
exposure to the agent is necessary.

[ Q: 1869 ] MRCPass - 2010 January

# A 60-year-old man is admitted with
chest pain to the Emergency Department. He
has a past medical history of type 2 diabetes,
hypertension and high cholesterol. His regular
medications includes simvastatin, bisoprolol,
glibenclamide and metformin. An ECG shows
ST elevation in the anterior leads and he is
referred for primary angioplasty. Following
the procedure, he was transferred to the
Coronary Care Unit (CCU). He has a blood
glucose measurement of 15 mmol/l.

Which drug regime should be commenced?

1- Continue metformin and glibenclamide at
same dose

2- Stop metformin and increase dose of
glibenclamide

3- Subcutaneous insulin: basal-bolus regime

4- Subcutaneous insulin: biphasic insulin
regime

5- Intravenous sliding scale insulin

Answer & Comments

Answer: 5- Intravenous sliding scale insulin

It has been shown from previous trials (e.g.
DIGAMI study) that insulin based glucose
management leads to improved outcomes in

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type 2 diabetes post myocardial infarction.
Good glycaemic control can be achieved with
a sliding scale insulin regime or Glucose Insulin
Potassium (GIK) regime.

^ [ Q: 1870 ] MRCPass - 2010 January

n -

# A 30 year old lady has recurrent
episodes of lip sw elling and is suspected of
having hereditary angioedema.

Which of the following is deficient in patients
with the condition?

1- C3

2- C6

3- Cl esterase inhibitor

4- Heat shock protein type 1

5- Histamine degradation protein (HDP)

Answer & Comments

Answer: 3- Cl esterase inhibitor

On examination, he was afebrile, his blood
pressure. Blood pressure was 130/80 mm Hg
and pulse was 72 per minute and regular. He
had partial ptosis of his right eye, conjunctival
congestion and miosis. His fundoscopy, visual
acuity and eye movements were normal. The
rest of his neurological examination was
normal. There was no carotid bruit. There
were no signs of meningism nor a rash.

What investigation should be done?

1- Skull X ray

2- MRI of the head

3- MRI and MRA of the neck

4- CT head

5- EEG

Answer & Comments

Answer: 3- MRI and MRA of the neck
The diagnosis is Horner's syndrome.

In Cl esterase inhibitor deficiency, sw elling of
the face, stridor and limbs can develop.

In Cl esterase inhibitor deficiency, the
complement factors C2 and C4 are low and Cl
esterase inhibitor level is also low . Episodes
can be precipitated by trauma or even an
allergen such as peanuts.

This patient needs to have carotid artery
dissection excluded due to the acute nature of
the presentation and conjunctival congestion.
However, a space occupying lesion, a brain
stem CVA, trauma to the neck and also
Pancoasts' tumour may all cause Horner's
syndrome.

[ Q: 1871 ] MRCPass - 2010 January

A 39-year-old man presented with a
1 week history of right sided neck pain with
associated headache, gradual in onset and not
associated with visual symptoms. The pain
had no diurnal variation, was not associated
with premonitory symptoms, fever or
vomiting. There were no known precipitating
factors and no history of trauma.

His wife also mentioned that his right eye
looked funny. There was no associated limb
weakness or sensory symptoms. He was
started on Sumatriptan by the general
practitioner but it did not relieve the pains.

[ Q: 1872 ] MRCPass - 2010 January

A 72 years old woman was admitted
with complaints of anorexia, nausea and
lethargy for last 4 months. She had history of
fall 12 months back after which she sustained
mild compression fracture of LI vertebra.
After the fall, she has had persistent
backaches. On examination, she was pale, BP
was 160/90 mmHg and bilateral pedal
oedema. There was tenderness over the
upper lumbar region.

Blood tests showed:

Hb 10.5 g/dl, WCC 7 x 10 9 /l, platelets 220 x
10 9 /l, ESR 90 mm/hr, sodium 135 mmol/I,
potassium 4.2 mmol/l, urea 16 mmol/I,

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creatinine 240 |imol/l. IgA 3.2 (0.5-4.0) g/l ,
IgG 23 (5.0-13.0) g/l, IgM 2.3 (0.3-2.2) g/l.

Routine urine examination showed urine
albumin trace, urine protein/creatinine ratio
2.7 and urinary Bence Jones protein was
positive.

What is the likely diagnosis?

1- Waldenstrom's macroglobulinaemia

2- Multiple myeloma

3- Chronic myeloid leukaemia

4- Acute lymphocytic leukaemia

5- Osteoporosis

Answer & Comments

Answer: 2- Multiple myeloma

The presence of unexplained anemia, kidney
dysfunction, a high erythrocyte sedimentation
rate (ESR) and a high serum paraprotein with
bence jones proteinuria suggests multiple
myeloma.

[ Q: 1873 ] MRCPass - 2010 January

A 20 year old woman presented 6
hours after taking 30g of Paracetamol.

Which of following factors is likely to predict
an increased risk of hepatotoxicity from
Paracetamol?

1- Anorexia nervosa

2- Consumption of 20 units of alcohol since
taking Paracetamol

3- Gilbert's disease

4- Ingestion of Amitriptyline

5- Smoking 20 cigarettes per day

Answer & Comments

Answer: 1- Anorexia nervosa

High risk groups in paracetamol overdose
include malnourished patients (anorexia
nervosa/bulimia nervosa), patients taking

enzyme inducing drugs (eg carbamazepine,
phenytoin rifampicin St John's Wort), patients
induced liver enzymes due chronic ethanol
abuse HIV positive patients.

[ Q: 1874 ] MRCPass - 2010 January

A 50 year old patient with polycystic
kidneys is undergoing investigations for a
renal transplant.

His blood group is O positive. His brother who
is 45 year old, is being considered as a
transplant donor. The brother has a normal
ultrasound of the kidneys with no renal cysts
and is blood group A positive.

Why is he unsuitable to become a kidney
donor?

1- Risk of developing polycystic kidneys

2- ABO incompatibility

3- Rhesus incompatibility

4- Risk of CMV reaction

5- HLA incompatibility leading to acute
rejection

Answer & Comments

Answer: 2- ABO incompatibility

There are glycoproteins in both groups A and
B which may stimulate antibodies tow ards
them.

People with blood group A cells have
antibodies to B, a donor with group B blood is
not compatible with a group A recipient.
Similarly, those with blood group B have
antibodies to group A, indicating a type A
donor is not compatible with a type B
recipient. Individuals with type AB cells lack
such antibodies and are therefore compatible
with any potential donors (with regard to
blood type matching).

As in the case above, a patient with blood
group O will have antibodies against both
those with group A and B and therefore
require blood group O kidney donors.

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Rhesus grouping is not as important in
transplant blood group matching but a rhesus
positive patient (particular Rhesus D
subgroup) may cause a rhesus negative
patient to generate antibodies and cause
subsequent rejection.

HLA matching is less important than ABO
compatibility in transplantation.

[ Q: 1875 ] MRCPass - 2010 January

A 38-year-old man presented with
visual symptoms which were new . He has no
relevant past medical history.

On examination, he had ptosis, miosis and
anhydrosis of his right eye, conjunctival
congestion and miosis.

What investigation should be done?

1- Chest X ray

2- CT scan of the head

3- MRI of the head

4- Ultrasound of the neck

5- EEG

Answer & Comments

Answer: 1- Chest X ray

The diagnosis is Horner's syndrome. The first
investigation should be a chest X ray which
will Pancoasts' tumour or a cervical rib which
can cause compression of the sympathetic
nervous supply.

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[ Q: 1876 ] MRCPass - 2010 May

A 43 year old female patient
presented in to clinic with a generalised
blistering rash on the arms and legs. Clinical
examination revealed tense skin blisters with
some generalised desquamation.

What should be done to confirm the
diagnosis?

1- Skin scrapings

2- Skin swab for microscopy and sensitivity

3- Blister fluid to be sent for viral culture

4- Immunofluorescence of skin biopsy

5- Trial of steroids

Answer & Comments

Answer: 4- Immunofluorescence of skin biopsy

The diagnosis is bullous pemphigoid, which is
a chronic, autoimmune, subepidermal,
blistering skin disease that rarely involves
mucous membranes.

Bullous pemphigoid is characterized by the
presence of immunoglobulin G (IgG)
autoantibodies in the hemidesmosomal area.
This manifests as tense blisters. Direct
immunofluorescence of a skin biopsy usually
demonstrate IgG and complement C3
deposition in a linear band at the dermal-
epidermal junction.

[ Q: 1877 ] MRCPass - 2010 May

A 52-year-old female presented with
two month history of an itchy rash which
appeared on her wrist and on the upper arms.
There was no relevant past medical, family or
drug history.

On examination there were annular flat
violaceous lesions on the arms.

Where else are lesions likely to be found?

3- Plantar surface

4- Perineal area

5- Scalp

Answer & Comments

Answer: 2- Buccal mucosa

There is an increased incidence of lichen
planus in several diseases in which there is
autoimmune phenomena.

Lichen planus (LP) is a pruritic, papular
eruption characterized by its violaceous color;
polygonal shape; and, sometimes, fine scale.

The initial lesion is usually located on the
flexor surface of the limbs, such as the wrists.

After a week or more, a generalized eruption
develops with maximal spreading within 2-16
weeks. Oral lesions such as on the buccal
mucosa may be present and either
asymptomatic or have a burning sensation, or
they may even be painful if erosions are
present. Characteristic fine, white lines, called
Wickham stria, are often found on the
papules.

[ Q: 1878 ] MRCPass - 2010 May

A patient was given magnesium
sulphate for treatment of acute asthma. Given
that the drug's half life is 4 hours, what
proportion of the drug is left after 20 hours?

1- 3.125%

2- 6.25%

3- 25%

4- 66%

5- 97%

Answer & Comments

Answer: 1- 3.125%

1- Behind the ears

2- Buccal mucosa

The proportion eliminated are:
4 hrs - 50%

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4 hrs - 25%

4hrs -12.5%

4hrs - 6.25%

4 hrs-3.125%

It adds up to 96.875 eliminated, or 3.125% of
the drug left.

^ [ Q: 1879 ] MRCPass - 2010 May

fm -

# A patient is being worked up for
renal transplantation.

Which one of the following HLA compatibility
is the most important?

1- A

2- B

3- C

4- D

5- G

Which one of the following is the most
appropriate next investigation?

1- Ankle-brachial pressure index

2- Lower limb arteriogram

3- Right leg venogram

4- Venous duplex ultrasound scan

5- Swab of the ulcer

Answer & Comments

Answer: 1- Ankle-brachial pressure index

This is likely to be a venous ulcer due to
venous insufficiency.

However, excluding arterial disease with the
anklebrachial pressure index is important to
ensure that any further treatment
(compression bandaging) will not exacerbate
symptoms. For cases with a clinical suspicion
of DVT then duplex ultrasound is indicated.

Answer & Comments

Answer: 4- D

ABO blood group matching is the most
important, and HLA matching is a relatively
minor predictor of transplant outcomes.

However, among HLA matches, DR matching
has a greater effect than that of B or A. A
study found that HLA-DR mismatches (and the
number of rejection episodes) correlated with
poor long-term survival

[ Q: 1880 ] MRCPass - 2010 May

A 65-year-old woman presented
with an ulcer over the left ankle, which had
developed over the previous 6 months. She
had a history of right deep vein thrombosis
five years previously. On examination she had
a superficial slough-based ulcer, 4 cms in
diameter, over the medial malleolus with no
evidence of cellulitis.

[ Q: 1881 ] MRCPass - 2010 May

A 25 year old man has pain in his
elbow and arm. He describes an injury whilst
using a hammer. On examination, there is loss
of sensation in the medial (little finger and
half of ring finger) of the hand and loss
sensation in medial side of the forearm, after
elbow injury.

What is the likely injury?

1- Axillary nerve injury

2- Median nerve injury

3- Ulnar nerve injury

4- Lateral epicondylitis

5- Tennis Elbow

Answer & Comments

Answer: 3- Ulnar nerve injury

Sensation is supplied by the ulnar nerve to the
fifth finger and the ulnar part of the fourth
finger.

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Claw hand is typical of ulnar nerve injury.

The axillary nerve supplies the deltoid and
teres minor as well as the skin over the
deltoid.

The median nerve supplies the lateral two
lumbricals, opponens pollicis, abductor pollicis
brevis and flexor pollicis brevis (LOAF). Flexion
of the fingers and thumb abduction is supplied
by the median nerve.

Lateral Epicondylitis, or tennis elbow is caused
by inflammation of the common extensor
origin, at the lateral epicondyle of the
humerus. It causes pain in the elbow during
movement.

[ Q: 1882 ] MRCPass - 2010 May

A healthcare worker gets a deep
needlestick injury during phlebotomy. This
was from an asymptomatic HIV positive
patient who is not on anti-retroviral therapy.

What is the next step?

1- Give antiretroviral therapy with 3 drugs for
one month

2- Give antiretroviral therapy with 3 drugs for
three months

3- HIV antibody test immediately

4- Intravenous immunoglobulins

5- No treatment required

Answer & Comments

Answer: 1- Give antiretroviral therapy with 3
drugs for one month

In this case the risk is not well known (the viral
load and CD4 count of the patient who was
HIV positive).

It is therefore best to give a basic regimen of
post exposure prophylaxis. The basic regimen
consists of : 4 weeks of zidovudine (600 mg/d
in 2-3 divided doses) , lamivudine (150 mg
twice daily) and one other agent. Exposure to
patients with high risks such as full blow n

AIDS or high viral loads should be with an
extended regimen.

[ Q: 1883 ] MRCPass - 2010 May

A 50-year-old man with a past
medical history of hypertension was
investigated as an outpatient due to
symptoms of lethargy and nausea. Blood
results reveal : sodium 137 mmol/I, potassium
4.5 mmol/l, urea 22 mmol/l, creatinine 340
pmol/l. Ultrasound demonstrated a left kidney
of 8.9 cm and right at 9.3 cm.

What is the best investigation to perform
next?

1- MR angiography

2- Renal angiography

3- Repeat renal ultrasound

4- Renal biopsy

5- CT scan of the kidney

Answer & Comments

Answer: 1- MR angiography

The history of hypertension and small kidneys
suggests renovascular disease or renal artery
stenosis.

The best follow on tests are MR angiogram or
isotope (MAG-3) nuclear imaging to evaluate
renal arterial anatomy and function as these
tests are less invasive. Once the diagnosis is
certain, angiography with a view to
angioplasty should then be considered.

[ Q: 1884 ] MRCPass - 2010 May

A 68-year-old woman was admitted
to hospital because of facial weakness and
limb weakness. The patient noticed weakness
of the right arm and leg and diplopia on
waking in the morning. She had been diabetic
and hypertensive for the past 20 years. Her
medications included gliclazide, metformin
and insulin. On admission she was alert and

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had a blood pressure of 155/75 mm/Hg.
Cranial examination revealed a left 3rd nerve
palsy, dilated pupil on the left side and normal
ocular fundi. Examination of motor system
showed right-sided spastic weakness with
grade 4/5 power. Deep tendon reflexes were
brisk on the right side with upgoing plantar
response.

Where is the lesion?

5- Autoimmune screen

Answer & Comments

Answer: 2- X ray of the sacroiliac joints

This case is most likely ankylosing spondylitis,
which typically causes restricted spinal
movements due to chronic inflammatory
changes.

1- Medial longitudinal fasciculus

2- Posterior cerebellar

3- Midbrain

4- Pons

Pain and stiffness in the lower back or
buttocks, especially in the morning is typical of
sacroilitis. X rays will help to confirm the
diagnosis.

5- Medulla

[ Q: 1886] MRCPass-2010 May

0 Which one of the

following
is global

Answer & Comments

nerve/roots is affected if there

Answer: 3- Midbrain

wasting of small muscles of hand?

- „ . r .1 i . ^ , 1- Median nerve

Most of the lesions causing 3rd cranial nerve

nucleus are from dorsal midbrain infarction. 2- Radial nerve

This patient has Weber syndrome, which
results from a slightly more ventral lesion at
the level of the third cranial nerve fascicles in
the mid brain, with involvement of the
cerebral peduncle giving rise to contralateral
hemiplegia or hemiparesis along with
ipsilateral third cranial nerve palsy.

3- Ulnar nerve

4- C7

5- T1

Answer & Comments

Answer: 5- T1

[ Q: 1885 ] MRCPass - 2010 May

A 30 year old man has had a year's
history of bilateral hip pains and back pains.
There is no past medical history of trauma to
the back. Non steroidal anti-inflammatory
drugs helped to relieve his symptoms. He also
has reduced chest expansion and is unable to
touch the feet with his fingers when bending.

What is the best investigation to confirm the
diagnosis?

1- CT scan of the chest

Global wasting of hand indicate median and
ulnar nerve lesions; probably, with damage to
T1 root. In the hand, the median nerve
supplies the lateral two lumbricals, opponens
pollicis, abductor pollicis brevis, and flexor
pollicis brevis.

Wasting of the interossei (prominent guttering
of the back of the hand), of the web space
between thumb and index finger, and
softening and flattening of the hypothenar
eminence with sparing of abductor pollicis
brevis indicates an ulnar nerve lesion.

2- X ray of the sacroiliac joints

3- Lung function tests

4- HLA B27 testing

[ Q: 1887 ] MRCPass - 2010 May
A 16-year-old girl who had been

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prescribed theophylline tablets 225 mg twice
a day took an overdose of 40 tablets,
following a stressful event.

She presented to hospital 1 hour and 30
minutes after the overdose. Her BP was
100/70 and she had a sinus tachycardia with a
heart rate of 130.

What is the best management option?

1- Activated charcoal

2- Gastric lavage

3- Whole bowel irrigation

4- Esmolol

5- Haemodialysis

[ Q: 1888 ] MRCPass - 2010 May

A 16-year-old boy was admitted to
hospital after a blackout at dentist. His mother
described how he looked pale and then
blacked out as a dentist began performing a
filling when he was sat in a chair. His arm
jerked for a few seconds and following the
event he was incontinent. He aw oke after a
minute was oriented. He was not confused
but did not recall what happened.

What is the likely diagnosis?

1- Complex partial seizure

2- Pseudoseizure

3- Stokes-Adams attack

Answer & Comments

Answer: 1- Activated charcoal

4- Tonic-clonic seizure

5- Vasovagal syncope

It is too late for gastric lavage, hence activated
charcoal is the best option here.

Theophylline is absorbed rapidly and
completely after oral administration.
Therapeutic serum levels range from 10-20
mcg/mL. Toxic levels are considered to be
higher than 20 mcg/mL; However, adverse
effects may be evident within the normal
therapeutic range. Severe complications
including cardiac dysrhythmias, seizures, and
death can be observed with the levels

of 80-100 mcg/mL. The therapeutic options
are as below :

Answer & Comments

Answer: 5- Vasovagal syncope

Vasovagal syncope is common during a
stressful event such as dental procedures,

There is no post event confusion and he
recovered very quickly, hence this makes a
genuine seizure unlikely. The description of
pallor, brief syncope and also shaking of arms
and limbs is consistent with vasovagal syncope
which is commonly mistaken for a seizure. It
can be associated with urinary incontinence
which is not specific for epileptic seizures.

Gastric lavage (unless contraindicated) if the
patient has recently (<1 h) ingested a
significant amount or a sustained-release
preparation of theophylline.

Multidose activated charcoal (MDAC)
enhances elimination of theophylline. It is a
very effective method of elimination, and it is
considered the mainstay treatment of
theophylline toxicity.

Consider whole-bow el irrigation (WBI) in
patients with exposure to sustained-release
theophylline preparations.

[ Q: 1889 ] MRCPass - 2010 May

A 32 year old female patient was
referred by the GP for assessment of unequal
sized pupils. On examination, it was found
that the right pupil was larger than the left.
The pupillary reflex on the right eye was also
sluggish both to light and accomodation. After
performing the accommodation reflex, the
pupil on the right was smaller than the left for
several minutes. Eye movements and
fundoscopy were normal.

What is the diagnosis?

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1- Argyll Robertson pupil

2- Horner's syndrome

3- Adie Holmes pupil

4- Myasthenia gravis

5- 3rd nerve palsy

Answer & Comments

Answer: 3- Adie Holmes pupil

Holmes-Adie syndrome (HAS) is a neurological
disorder affecting the pupil of the eye and the
autonomic nervous system.

Once the pupil has constricted it remains small
for an abnormally long time (tonic pupil),
hence in this case after the pupils were
constricted following the accommodation test,
the right adie pupil remained smaller than the
left.

[ Q: 1890 ] MRCPass - 2010 May

A 30-year-old Caucasian woman
admitted has a history of widespread, pruritic,
erythematous skin rash, joint pains and renal
disease. She recently had a baby with
congenital heart block. Laboratory
investigations revealed mild leucopenia (white
cell count 3.25xl09/ml) and
thrombocytopenia (platelets 140xl09/ml).
Erythrocyte sedimention rate was increased
(65 mm/h).

Which antibody is likely to be positive?

1- Anti Jo 1

2- Anti double stranded DNA

3- Anti Ro

4- Anti centromere

5- ANCA

Answer & Comments

Answer: 3- Anti Ro

The anti Ro antibody is associated with
Sjogren's syndrome, SLE and neonatal lupus.

In neonatal lupus, congenital heart block often
occurs in babies born to women with the
antibody (both anti Ro and anti La antibodies).

[ Q: 1891 ] MRCPass - 2010 May

A 52 year old patient with
syringomyelia has a syrinx demonstrate
unilaterally at the level of C4-T1.

Whot is the likely manifestation for the
patient?

1- Loss of pinprick and vibration sense in the
hand on the contralateral

2- Loss of pain and temperature sensation in
the hand on contra lateral side

3- Winging of the scapula in the contralateral
side

4- Hand weakness in the contralateral side

5- Leg weakness in the contralateral side

Answer & Comments

Answer: 2- Loss of pain and temperature
sensation in the hand on contra lateral side

Syringomyelia is a chronic disorder
characterized by the presence of a
longitudinal, fluid filled cavities (syrinx) within
the spinal cord.

The question tests know ledge of anatomical
pathw ays. This is a one sided lesion of the
spinal cord. Such a lesion will cause:

a unilateral motor deficit below the lesion (the
corticospinal tract decussates at the medulla)

a unilateral reduction in vibration sense
(dorsal columns decussates at the medulla)

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a contralateral pain and temperature sensory
deficit (the spinothalamic tract decussates at
the same level at the spinal cord).

Winging of the scapula (C5-7) and hand
weakness may both occur, but in this case is
on the wrong side.

[ Q: 1892 ] MRCPass - 2010 May

An 18-year-old woman is admitted
to the resuscitation room with respiratory
distress and a GCS score of 3/ 15.

She had been found unconscious at home.
Blood gases and blood test results taken on
admission show the following:

pH 6.92

pC02- 2.5 kPa

p02 -16.8 kPa

Na+ 143 mmol/I

K+ 4.6 mmol/I

Chloride 101 (95-107) mmol/I

Bicarbonate 3.2 (20-28) mmol/l

Urea 5.2 mmol/l

Creatinine 60 |imol/l

Glucose 7 mmol/l

Methanol 523 mg/dl

Whot is the best treatment option?

1- Observation only

2- Insulin sliding scale

3- Haemodialysis

4- Ethanol

5- Fomepizole

Answer & Comments

Answer: 3- Haemodialysis

In this case there is severe neurological signs
and the patient has a high methanol level with
metabolic acidosis, hence haemodialysis is the
best option.

Methanol is a commonly used organic solvent,
the ingestion of which can cause significant
toxicity. It is a constituent in many
commercially available industrial solvents and
in poorly adulterated alcoholic beverages.
Toxicity usually results in metabolic acidosis,
neurologic damage (ataxia, coma), blindness
(formic acid accumulates within the optic
nerve).

Antidote therapy is directed tow ards delaying
methanol metabolism until the methanol is
eliminated from the system either naturally or
via dialysis. This is often accomplished in 2
ways: ethanol or fomepizole. Ethanol is also
metabolized by ADH, and the enzyme has 10-
20 times higher affinity for ethanol compared
with methanol.

Fomepizole is also metabolized by ADH;
However, its use is limited because of high
costs and lack of availability.

Hemodialysis can easily remove methanol and
formic acid. Indications include (1) greater
than 30 mL of methanol ingested, (2) serum
methanol level greater than 20 mg/dL, (3)
observation of visual complications, and (4) no
improvement in acidosis despite repeated
sodium bicarbonate infusions.

[ Q: 1893 ] MRCPass - 2010 May

A 35 year old woman has
longstanding breathlessness. Previous
investigations have shown that she has
multiple chronic pulmonary emboli.

Which one of the following would be a
consistent finding?

1- Normal pulmonary wedge pressure

2- Increased inspiratory reserve volume

3- Decreased transfer factor

4- Increased lung compliance

5- low FEV1/FVC ratio (obstructive picture)

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Answer & Comments

Answer: 3- Decreased transfer factor

Transfer factor and alveolar volume are
significantly lower in patients with pulmonary
emboli.

Pulmonary wedge pressure is increased in
pulmonary veno-occlussive disease.

^ [ Q: 1894 ] MRCPass - 2010 May

h -

m A 25 year old woman presented with
confusion and severe headache following a
night out at a club. On examination, the
following were found heart rate: 150
beats/min with sinus tachycardia on the
monitor, blood pressure: 160/90 mmHg,
respiratory rate: 30, oxygen saturation by
pulse oximetry was 98%. Her GCS score was
14/15.

Which one of the following conditions is most
likely to couse this?

1- Cluster headache

2- Meningitis

3- Paracetamol overdose

4- Ecstasy overdose

5- Venous sinus thrombosis

tablets for depression and has recently been
found to be hypertensive with a blood
pressure of 170 / 95 mmHg.

Whot should be the preferred drug?

1- Verapamil

2- Doxazosin

3- Amlodipine

4- Hydrochlorothiazide

5- Ramipril

Answer & Comments

Answer: 3- Amlodipine

Diuretics may increase the amounts of lithium
in the body (hydrochlorothiazide,
acetazolamide, furosemide).

Other antihypertensive drugs which may
increase or worsen the side effects of lithium
e.g. some calcium channel blockers (i.e.
verapamil, diltiazem) and Angiotensin
converting enzyme inhibitors (i.e. enalapril,
captopril, ramipril).

Amlodipine or doxazosin can both be used,
but amlodipine should be picked first in this
instance.

^ [ Q: 1896] MRCPass-2010 May

Answer & Comments

—1 # A 65 year old female with a history

Answer: 4- Ecstasy overdose

MDMA (ecstasy) is a popular drug of abuse for
its combined properties inherent to those of
amphetamines and hallucinogens.

of type 2 diabetes, hyperparathyroidism and
osteoarthritis has recurrent knee pains. On
examination, she was apyrexial and found to
have a right sided knee effusion. The effusion
was aspirated.

Symptoms of MDMA ingestion include an
altered mental status, tachycardia, tachypnea,
sweating and hyperthermia. Severe cases can
progress to rhabdomyolysis, acute renal
failure, cardiac collapse, and disseminated
intravascular coagulation.

Whot is the likely finding in synoviol fluid
o no lysis?

1- Star shaped crystals

2- Yellow maltese cross crystals

3- Positively birefringent rhomboid crystal

[ Q: 1895 ] MRCPass - 2010 May
A 45 year old man is on lithium

4- Positively birefringent needle shaped
crystal

5- Negatively birefringent crystal

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Answer & Comments

Answer: 3- Positively birefringent rhomboid
crystal

In the case of an acute attack of arthritis
(usually monoarthritis), the joint should alw
ays be aspirated.

The differential diagnosis lies between septic
arthritis, gout and pseudogout. Gout and
pseudogout are the 2 most common crystal-
induced arthropathies. These are debilitating
illnesses in which pain and joint inflammation
are caused by the deposition of crystals within
the joint space. Many cases of pseudogout are
idiopathic, but it has also been associated with
aging, trauma, and many different metabolic
abnormalities like hyperparathyroidism (as in
this case) and hemochromatosis. Pseudogout
is an inflammation caused by the deposition of
positively birefringent rhomboid shaped
calcium pyrophosphate dihydrate (CPPD)
crystals. Gout crystals are negatively
birefringent.

[ Q: 1897 ] MRCPass - 2010 May

A 62 year old man fell over and lost
consciousness for several minutes. He was
brought to hospital and was initially alert.
However, 2 hours later, whilst he was being
admitted, he complained of a headache and
his GCS deteriorated from 15 to 8.

sudden deterioration in conscious level with
an associated headache is a subdural
haematoma.

This patient needs an urgent CT scan in view
of the deterioration.

[ Q: 1898 ] MRCPass - 2010 May

A 62-year-old man with a recent
history of colorectal carcinoma presented to
hospital with exertional dyspnea, fever and
malaise. He had altered bow el habit for
several weeks prior to his admission. On
examination his temperature was 39,5°C ,
there was sinus tachycardia of 105 beats/min
and respiratory rate was 32/minute. He had
several splinter haemorrhages, there were
clear breath sounds and a systolic murmur
was heard along the apex and diastolic
murmur at the right second intercostal area.

Whot is the most likely infective organism?

1- Streptococcus mitis

2- Streptococcus bovis

3- Streptococcus viridans

4- Staphylococcus aureus

5- Streptococcus milieri

Answer & Comments

Answer: 2- Streptococcus bovis

Whot is the most likely diagnosis?

1- Subarachnoid haemorrhage

2- Subdural haematoma

3- Extradural haematoma

4- Diffuse axonal injury

5- Epileptic seizure

Answer & Comments

Answer: 2- Subdural haematoma

The patient who fell over may have injured his
head and the most likely cause of a further

Strep bovis can be found in the normal flora of
human gastrointestinal system.

S. bovis endocarditis is often associated with
colonic carcinoma. It is the second common
Streptococci causing bacterial endocarditis.

[ Q: 1899 ] MRCPass - 2010 May

A 70 year old man is assessed in the
pre operative assessment clinic for a hip
replacement. During the preoperative
assessment was noted to have a raised
lymphocyte count. On examination, he had
lymphadenopathy palpable in the cervical and

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axillary area. A spleen was palpable 3 cm
below the costal margin.

His bloods were as follows:

Hb 11.6 g/dl

Pit 164 x 10 9 /l

WBC 45.2 x 1071

What is the likely diagnosis?

1- Acute lymphocytic leukaemia

2- Acute myeloblastic leukaemia

3- Chronic lymphocytic leukaemia

4- Chronic myeloblastic leukaemia

5- Multiple myeloma

Answer & Comments

Answer: 3- Chronic lymphocytic leukaemia

Chronic lymphocytic leukemia (CLL), is the
most common type of leukemia and it affects
B cell lymphocytes.

Most (>75%) people newly diagnosed with CLL
are over the age of 50, and the majority are
men. Most people are diagnosed without
symptoms as the result of a routine blood test
that returns a high white blood cell count.
Clinical signs of lymphadenopathy and
splenomegaly are associated.

[ Q: 1900 ] MRCPass - 2010 May

A 40-year-old female patient, an ex¬
smoker with an 8-pack-year smoking history
and severe pulmonary emphysema of early
onset. Her father has a diagnosis of 1-
antitrypsin (AAT) deficiency. Her serum
antitrypsin levels are measured to be
approximately 15% of the normal range.

Which genotype is most likely?

1- ZZ

2- MZ

3- SZ

4- MM

5- SS

Answer & Comments

Answer: 1- ZZ

The commonest phenotype is Protease
Inhibitor (Pi) MM (90% of the population have
this).

These individuals produce normal amounts of
alphal-antiprotease. The most common form
of AAT deficiency is associated with allele Z, or
homozygous PiZ (ZZ). Serum levels of AAT in
these patients are about 3 - 7 umol/L (10-15%
of normal serum levels). Emphysema develops
in most (but not all) individuals with serum
levels less than 9 mmol/L.

[ Q: 1901 ] MRCPass - 2010 May

A 34 year old lady attends clinic for
evaluation of pain or sw elling in the wrists,
small joints of her hands or feet.

She denied morning stiffness, subcutaneous
nodules or sicca symptoms. Rheumatoid
arthritis is suspected. In the process of disease
evaluation, HLA class is considered.

Which HLA type is associated?

1- DR2

2- DR4

3- DR3

4- B27

5- DQ8

Answer & Comments

Answer: 2- DR4

90% of patients with Rheumatoid arthritis
have the cluster of markers known as the HLA-
DR4/DR1 cluster, whereas only 40% of
unaffected controls do.

The HLA-DR4 gene, has also shown
involvement in Lyme disease.

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Patients with HLA-DR4 are less likely to
respond to antibiotics.

the elbows, knees and ankles.
Thrombocytopenia is also a common finding.

[ Q: 1902 ] MRCPass - 2010 May

A 52-year-old woman presents with
lethargy and ankle oedema. She has a past
medical history of hypertension and has
recurrent joint pains. She currently takes
ibuprofen and amlodipine. On examination
she was pyrexial, had livedo reticularis. Her
blood pressure was 175/100 mmHg.

Investigations revealed:

haemoglobin 12.2 g/dL (11.5-16.5)

white cell count 8.2 x 10 9 /L (4-11)

platelet count 83 x 10 9 /L (150-400)

urea 5 mmol/l

serum creatinine 155 umol/L
urine dipstick analysis:
blood +
protein +++

Which one of following is the likely diagnosis?

1- IgA nephropathy

2- Rheumatoid arthritis

3- Systemic lupus erythematosus

4- Polyarteritis nodosa

5- Wegener's granulomatosis

Answer & Comments

Answer: 3- Systemic lupus erythematosus

This patient features of suggest Systemic lupus
erythematosus (SLE) with possible
antiphopholipid syndrome and nephrotic
syndrome.

SLE can present with many features including
skin changes and vasculitic lesions,
hypertension, renal involvement and alopecia.
Livedo reticularis is a mottled, reticulated skin
rash- usually on the lower extremities, around

[ Q: 1903 ] MRCPass - 2010 May

A 55-year-old man with a 10-year
history of DM and hypertension, presents to
the renal clinic with complaints of fatigue and
shortness of breath. He is known to have
chronic kidney disease and has complications
of diabetic retinopathy and peripheral
neuropathy. He has been gradually becoming
more short of breath on exertion over the last
6 months. His blood test results are:

Hb 8.5 g/dl, MCV 85 fl, WCC 7x 10 9 /l, platelets
220 x 10 9 /l, sodium 135 mmol/l, potassium 4.6
mmol/l, urea 15 mmol/l, creatinine 310
pmol/l, calcium 2.2 (2.25-2.7) mmol/l,

phosphate 5 (0.8-8) pmol/l

What is the best way of managing his
symptoms?

1- Physiotherapy to increase exercise
tolerance

2- Erythropoietin treatment

3- Dialysis to improve renal function

4- Improve glycaemic control

5- Treat for pulmonary embolism

Answer & Comments

Answer: 2- Erythropoietin treatment

This patient has anaemia secondary to chronic
kidney disease, and patients who have
symptomatic anaemia (in this case, shortness
of breath limiting exercise tolerance) should
be considered for Erythropoietin treatment.

The renal association guidelines recommend
that patients with CKD on ESA therapy should
achieve haemoglobin between 10.5-12.5 g/dl.

http://w ww

.renal.org/Clinical/GuidelinesSection/Anaemia
InCKD.aspx

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^ [ Q: 1904 ] MRCPass - 2010 May

/ -1-I-

m A 22-year-old man returns from
holiday and presents to a clinic complaining of
numerous scaly, hypopigmented lesions on
the neck and upper trunk.

What is the likely diagnosis?

1- Chronic plaque psoriasis

Answer & Comments

Answer: 2- Praziquantel

Although schistosomiasis is endemic in Africa,
the Middle East, Latin America, and limited
areas in Asia, the greatest risk of infection
appears to come from exposure to freshw ater
in east Africa.

2- Discoid eczema

3- Pityriasis rosea

4- Pityriasis versicolor

5- Seborrhoeic dermatitis

Answer & Comments

Answer: 4- Pityriasis versicolor

Pityriasis versicolor is caused by a superficial
fungal infection by pityrosporum ovale.

It usually presents as slightly scaly
hypopigmented lesions. Growth is encouraged
by an increase in temperature, suntan oils and
is commonly seen after a sunny holiday.
Pityriasis rosea usually starts with a herald
patch followed by small scaly lesions following
rib lines.

[ Q: 1905 ] MRCPass - 2010 May

A 27 year old lady had recently
travelled to the Uganda several months ago.
She complained of fevers and headache. The
GP found that she had microscopic
haematuria on urine dipstick. A full blood
count showed Hb 10.6g/dL, MCV 82.6fl,
eosinophils 0.5 (0.04-0.44) x 10 9 /dL.

What should be prescribed?

1- Augmentin

2- Praziquantel

3- Fluconazole

4- Mebendazole

5- Caspofungin

Infection results from penetration of intact
skin by larvae liberated from snail
intermediate hosts.

Most infected travellers are asymptomatic
and at low risk of complications because of
low parasite burdens, although end-organ
damage may result from egg deposition.
Other presentations include sw immers' itch (a
popular pruritic dermatitis at the time of
exposure) and Katayama fever, which is
associated with the migration of schistosome
larvae throughout the body (symptoms
include fever, chills, malaise, headache, cough,
abdominal pain, diarrhoea, urticaria, and
occasionally neurological disorders).

Once egg deposition begins, clinical features
include haematuria, haematospermia,
urgency, frequency, terminal dysuria,
salpingitis, prostatitis and genital ulcers (case
history. More serious but rare complications
are paraparesis, paraplegia and mass cerebral
lesions. Immigrants and refugees from
endemic countries are likely to have much
heavier infection loads and may present with
the complications of chronic fibrosis, such as
ureteric obstruction and portal hypertension.

The standard treatment is praziquantel (20
nng/kg orally for two doses, four hours apart).
About 10%-15% of patients require re¬
treatment.

[ Q: 1906 ] MRCPass - 2010 May

A 55 year old man has been
diagnosed with Burkitt's Lymphoma.

Which gene mutation is associated?

1- BRAF

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2- P53

3- C-myc

4- N-myc

5- BCI-ABR

Answer & Comments

Answer: 3- C-myc

In Burkitt's lymphoma (associated with
Ebstein Barr virus), genetic translocations lead
to consequent c-myc rearrangement and
overexpression.

In most (approximately 90%) of the cases of
Burkitt's lymphoma, a reciprocal translocation
has moved the proto-oncogene c-myc from its
normal position on chromosome 8 to a
location close to the enhancers of the
antibody heavy chain genes on chromosome
141(8:14).

[ Q: 1907 ] MRCPass - 2010 May

A 20-year-old woman presented
with a 1-year history of progressive hair loss in
patches. She has a history of eczema and
hypothyroidism. On examination, in the
affected hair loss areas, the skin was pale and
waxy. The hair loss did not involve other body
sites but she had hypopigmented areas over
the arms. Blood tests show normal full blood
count, renal function and also negative ANA.

What is the likely diagnosis?

1- SLE

2- Hypothyroidism associated hair loss

3- Dermatitis artefacta

4- Allergic contact dermatitis

5- Alopecia areata

Answer & Comments

Answer: 5- Alopecia areata

Alopecia areata is a form of hair loss from
areas of the body, usually from the scalp.

The condition affects l%-2% of the
population. Hair loss may be diffuse or affect
areas, and commonly affects the scalp but can
also affect any hair growing part of the body.
It is commonly associated with autoimmune
diseases, such as hypothyroidism, SLE and also
vitiligo. Steroid creams such as clobetasol,
steroid injections or minoxidil are treatment
options.

[ Q: 1908 ] MRCPass - 2010 May

A 56 year old patient with atrial
fibrillation is on long term warfarin. He was
recently diagnosed with pulmonary
tuberculosis and was started on
antituberculosis agents. He mentioned that his
INR frequently decreased since then and the
anticoagulant nurses had to increase the dose
of warfarin.

Which antituberculosis agent was most likely
to have been responsible for the decrease in
INR?

1- Rifampicin

2- Pyrazinamide

3- Ethambutol

4- Isoniazid

5- Streptomicin

Answer & Comments

Answer: 1- Rifampicin

Rifampicin is a liver enzyme inducer and
isoniazid is a liver enzyme inhibitor.

Liver enzyme inducers are likely to reduce the
effect of warfarin, causing a decreased INR.

[ Q: 1909 ] MRCPass - 2010 May

Which one of the following is the
mechanism of action of the drug , clopidogrel?

1- Monoclonal antibody

2- Cyclooxygenase inhibitor

3- Glycoprotein llb/llla inhibitor

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4- ADP antagonist

5- Low molecular weight heparin

Answer & Comments

Answer: 4- ADP antagonist

Step 3:- Add inhaled long-acting B2 agonist
(LABA), such as salmeterol

If control still inadequate, institute trial of
other therapies, leukotriene receptor
antagonist or slow release theophylline

Clopidogrel and ticlopidine are adenosine
diphosphate (ADP)-receptor antagonists that
inhibit ADP-induced fibrinogen binding to
platelets, a necessary step in the platelet
aggregation process.

[ Q: 1910 ] MRCPass - 2010 May
A 23-year-old woman comes for

review.

She was diagnosed with asthma two years ago
and is currently using a salbutamol inhaler
lOOmcg PRN combined with beclometasone
dipropionate inhaler 400mcg twice a day. She
continues to get frequent episodes of
wheeziness and shortness of breath with low
peak flow readings. She has a good inhaler
technique.

Whot is the most appropriate next step in
management?

1- Switch steroid to fluticasone propionate

2- Increase beclometasone dipropionate to
800mcg bd

3- Trial of monteleukast

4- Add salmeterol

5- Add tiotropium

Answer & Comments

Answer: 4- Add salmeterol

The management of stable asthma is now well
established with a step-w ise approach:

Step 1:- Inhaled short-acting B2 agonist as
required

Step 2:- Add inhaled steroid at 200-800
mcg/day*

[ Q: 1911 ] MRCPass - 2010 May

A 43 year old man presents to the
hospital with shortness of breath and chest
pain.

He is a non smoker and has no previous
medical history of respiratory problems. His
BP was 110/80 & pulse was 80/min. CXR
shows a large pneumothorax and the patient
had 1.5 litres of air aspirated from the chest. A
repeat CXR show s, a maximum of 1.5 cm
diameter rim of air from the chest wall and
the patient remains short of breath.

Which is the most appropriate step?

1- Chest drain

2- Oxygen therapy

3- Observation and follow up

4- Repeat needle aspiration

5- VATs procedure

Answer & Comments

Answer: 4- Repeat needle aspiration

This patient has a symptomatic primary
pneumothorax which has been aspirated and
in the question the actual volume aspirated in
the first instance was also given.

A repeat aspiration is recommended if the
patient is still symptomatic after the first
aspiration (for a primary pneumothorax) and <
2.5 I of air was aspirated in the first attempt as
in this case.

See pg 44 of the BTS guideline

http://www.brit-thoracic.org.uk/clinical-

information/pneumothorax/pneumothorax-

guideline.aspx

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[ Q: 1912 ] MRCPass - 2010 May

A 25-year-old man presented with
bi- temporal hemianopia. He mentioned that
his shoe sizes were above that of his friends
since childhood and he often had sw eaty
episodes.

Which one of the following tests is likely to
confirm the diagnosis of acromegaly?

1- Random growth hormone

2- IGF-1

3- Glucose tolerance test with growth
hormone suppression

4- MRI pituitary Synacthen test

5- Synacthen test

Answer & Comments

Answer: 3- Glucose tolerance test with growth
hormone suppression

In Acromegaly, there is excess Growth
hormone (GH) which is difficult to suppress.

Because GH secretion is inhibited by glucose,
measurement of glucose non-suppressibility is
useful. In the glucose tolerance test, baseline
GH levels are obtained prior to ingestion of
100 g of oral glucose, and additional GH
measurements are made at 30, 60, 90, and
120 minutes following the oral glucose load.
Patients with active acromegaly are unable to
suppress GH concentration below 2 ng/mL.

Random GH measurements are often not
diagnostic because of the episodic secretion of
GH, but IGF-I has a long half-life, and is useful
as a screen for Acromegaly. MRI may reveal a
pituitary tumour but it would not be specific
for Acromegaly.

[ Q: 1913 ] MRCPass - 2010 May

A 69-year-old woman has lung
carcinoma and recently underwent
chemotherapy. She presented with shortness
of breath and pleuritic chest pain.

Which one of the following signs suggests a
significant pericardial effusion?

1- Systolic murmur

2- Pericardial rub

3- Rapid y descent of JVP

4- Rise of JVP with inspiration

5- rise in blood pressure with inspiration

Answer & Comments

Answer: 4- Rise of JVP with inspiration

The question asks for which signs are present
in cardiac tamponade due to a large
pericardial effusion.

The main signs are Kussmaul's sign (increase in
JVP with inspiration) and Pulsus paradoxus
(the inspiratory fall of aortic systolic pressure
greater than 10 mm Hg).

[ Q: 1914 ] MRCPass - 2010 May

A 60 year old lady is being assessed
for treatment of hypertension. She has a high
blood pressure despite being on
bendroflumethiazide. She has recently
discontinued medications due to ankle
oedema, gum bleeding and generalised
lethargy.

What medication should she be given?

1- Atenolol

2- Perindopril

3- Amlodipine

4- Verapamil

5- Frusemide

Answer & Comments

Answer: 2- Perindopril

Beta blockers may worsen lethargy and
calcium channel blockers can cause ankle
oedema and gum bleeding.

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A thiazide diuretic has already been started,
hence frusemide is not appropriate, hence an
ACE inhibitor such as perindopril is the best
option.

[ Q: 1915 ] MRCPass - 2010 May

A 20 year old cocaine abuser
presents with chest pain. On admission, he
has a blood pressure of 180 / 95 mmHg and is
agitated.

What serious complication is he most likely to
develop?

1- Hyponatraemia

2- Hypomagnesaemia

3- Hyperkalemia

4- Hyperthermia

5- Hypothermia

Answer & Comments

Answer: 4- Hyperthermia
Cocaine is a strong stimulant.

The most common acute risk is bacterial line
related infections such as staphylococcal,
which has been underreported.

The important long-term risks of transmitting
viral infection from the donor are well
recognised and have been substantially
reduced by screening of HIV and Hepatitis B +
C in developed countries.

[ Q: 1917 ] MRCPass - 2010 May

A 35 year old woman presents with a
history of intermittent light-headedness.

Clinical examination and 12-lead ECG were
normal.

Which of the following, if present on a 24 hour
Ho Iter ECG tracing, would be the most
clinically important?

1- Atrial premature beats

2- Profound sleep-associated bradycardia

3- Supraventricular tachycardia

4- Transient Mobitz type 1 atrioventricular
block

In significant cocaine overdoses, the main
effects are Acute coronary syndrome
(coronary vasospasm), Agitation and delirium,
Seizures and severe Hyperthermia.

[ Q: 1916 ] MRCPass - 2010 May

Which of the following types of
infections is most commonly transmitted
through platelet infusion?

1- HIV

2- Malaria

3- Hepatitis B

4- Staphylococcal

5- Treponema

Answer & Comments

Answer: 4- Staphylococcal

5- Ventricular premature beats

Answer & Comments

Answer: 3- Supraventricular tachycardia

The most significant arrhythmia here is
supraventricular tachycardia and

consideration should be given to a trial of
medication such as beta blocker.

Both atrial and ventricular premature beats,
sleep associated bradycardia and transient
second degree (mobitz) heart block do not
need intervention.

[ Q: 1918 ] MRCPass - 2010 May

A 48-year-old white male who is HIV
positive presented to the emergency
department with a 10-day history of jaundice
and a 4-day history of right upper quadrant
and midepigastric abdominal pain. He gives a

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history of recent unprotected sexual
intercourse. His most recent CD4+ cell count
was 520 /|iL with a viral load of less than 400
HIV RNA copies/mL.

On physical examination, his abdomen was
moderately distended, with marked
tenderness in the right upper quadrant, and
both his liver and spleen were 5 cm below the
costal margin. Laboratory assessment showed:

Bilirubin 32 (1-22) pmol/l, serum alkaline
phosphatase, 138 IU/L (30 to 115 IU/L); serum
aspartate and alanine transaminases, 75 and
88 IU/L,(normal, 5 to 45 IU/L and 5 to 60 IU/L).

What is the most likely cause of hepatitis in
this patient?

1- Cytomegalovirus

2- Ebstein barr virus

3- Hepatitis B virus

4- Hepatitis C virus

5- Hepatitis E virus

Answer & Comments

Answer: 4- Hepatitis C virus

This questions asks what the commonest
cause of viral co-infection causing hepatitis in
HIV patients.

The highest prevalence of viral co-infection
among HIV infected patients is hepatitis C.

[ Q: 1919 ] MRCPass - 2010 May

A 25-year-old man presented to the
emergency department with fevers. He drinks
4 units of alcohol per day and admitted to
regular intravenous drug abuse. On physical
examination, the patient had a temperature of
38°C, was tachypnoeic and tachycardic. Blood
pressure was 100/85 mmHg. He had a soft
systolic murmur heard throughout the
precordium.

What is the most likely infective organism?

1- Staph viridans

2- Staph epidermidis

3- Staph aureus

4- Pneumocystis carinii

5- Streptococcus pyogenes

Answer & Comments

Answer: 3- Staph aureus

In this case, due to a history of intravenous
drug use, tricuspid valve endocarditis is most
likely.

Among intravenous drug users, staph aureus
is the most common cause. In patients with
native valve endocarditis, staph viridans is the
most common.

[ Q: 1920 ] MRCPass - 2010 May

A 42-year-old woman who is known
to be HIV positive is admitted to the
Emergency Department following a seizure.
Her partner reports that she has been having
headaches, night sweats and anorexia for the
past four weeks. Blood tests and a CT head are
arranged:

CD4 80 cells/mm

CT head - Single ring enhancing lesion in the
right parietal lobe with surrounding oedema

What is the most likely diagnosis?

1- CNS lymphoma

2- Tuberculosis

3- Progressive multifocal

leukoencephalopathy

4- Brain abscess

5- Toxoplasmosis

Answer & Comments

Answer: 1- CNS lymphoma

The best options are either lymphoma or
toxoplasmosis, but key to differentiating is
whether it is single or multiple.

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With cerebral lymphoma, a single lesion that
enhances in a nodular, homogeneous, or ring¬
like pattern is observed, typically with
surrounding cerebral oedema.

Toxoplasmosis is the most common cause of
brain lesions in HIV patients.

In this patient, rosiglitazone is contraindicated
due to heart failure and metformin is
relatively contraindicated due to renal
impairment. The BMI is high and as a second
line agent after sulphonylurea and insulin,
exanetide should be considered.

The majority of lesions (90%) are However,
mulltiple on presentation, so is less likely in
the above scenario.

Tuberculous infection is much more varied
radiologically, with meningeal destruction and
Granulomas.

^ [ Q: 1921 ] MRCPass - 2010 May

f* -

# A 55 year old lady is being reviewed
in the diabetes clinic. She has type 2 diabetes
which is poorly controlled and a history of CCF
with moderately impaired left ventricular
function. Her BMI is 35. She is currently on
gliclazide 160mg bd, a long acting glargine
insulin and short acting actrapid insulin with
meals, frusemide, amlodipine and
bendrofluazide. Her HbAlc value is 12 and she
has frequently high BMS recorded. Her latest
U&E results are urea 10 mmol/I, creatinine
190 pmol/l.

Whot is the best medication to odd to control
her blood sugars?

1- Rosiglitazone

^ [ Q: 1922 ] MRCPass - 2010 May

# A 64 year old man presents with an
episode of amnesia for the second time. 2
days ago he had an episode of confusion,
according to his wife. He was, However, able
to have a normal conversation despite having
been found wandering. After 2 hours, he
abruptly returned to normal and could not
remember what happened.

Whot is the most likely diagnosis?

1- Alcoholic encephalopathy

2- subarachnoid haemorrhage

3- Complex partial seizure

4- Transient ischaemic attack

5- Transient global amnesia

Answer & Comments

Answer: 5- Transient global amnesia

Transient global amnesia (TGA) is a temporary
and isolated disorder of memory which may
last several hours.

2- Metformin

3- Exanetide

4- Glimepiride

5- Glucagon

Answer & Comments

Answer: 3- Exanetide

The newer incretin (GLP) analogues are now
included in the guidelines by NICE CG 66 for
patients who have not responded to insulin
and Thiazolidinediones.

Precipitating factors include sexual
intercourse and heavy physical exercise,
particularly sw imming in cold water.

[ Q: 1923 ] MRCPass - 2010 May

A 65-year-old comes to the clinic for
a review of his symptoms.

He has been followed up for aortic stenosis for
the last 10 years. Over the past three months
he has been complaining of fatigue and has
lost 8 kg in weight. A full blood count was
requested:

Hb9.2 g/dl

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MCV 65 fl
Pit 360 x 10 9 /l
WBC 5.0 xl0 9 /l

Blood film Hypochromic, microcytic picture

An upper Gl endoscopy and duodenal biopsy
was normal.

Answer & Comments

Answer: 3- Aspirin

Several large trials have demonstrated that
aspirin improves prognosis in unstable angina
and reduces the risks of cardiovascular events
such as myocardial infarction.

What is the most appropriate next
investigation?

1- Transthoracic echocardiogram

2- Bone marrow biopsy

3- Colonoscopy

4- Faecal occult blood

5- Mesenteric angiography

Answer & Comments

Answer: 3- Colonoscopy

The patient may have angiodysplasia, which is
associated with aortic valve disease.

There is evidence of iron deficiency anaemia.
Although the OGD is normal, a colonoscopy
should be considered as it can investigate
higher for sources of bleeding.

The other drugs are all good antianginal drugs
for symptomatic management.

[ Q: 1925 ] MRCPass - 2010 May

A 40 year old man has palpitations
and ECG shows atrial fibrillation. This resolves
spontaneously. The next day, the ECG was
normal. Echocardiography reveal normal
cardiac anatomy. The patient describes weekly
episodes of palpitations.

Which of the following should be started for
maintenance of sinus rhythm?

1- Digoxin

2- Flecainide

3- Amlodipine

4- Bretylium

5- Ramipril

^ [ Q: 1924 ] MRCPass - 2010 May

# A 50 year old man with worsening
angina was referred for an exercise test. The
Bruce protocol exercise test was positive with
recordings showing 2-3 mm ST depression in
the anterior leads.

Answer & Comments

Answer: 2- Flecainide

Flecainide is a class Ic antiarrhythmic (sodium
channel blocker) which is useful for
paroxysmal AF.

Which one of the following drugs is likely to
improve prognosis?

1- Isosorbide mononitrate

2- Diltiazem

3- Aspirin

4- Nicorandil

5- Ivabradine

Other helpful options are beta blockers
(sotalol) and amiodarone.

[ Q: 1926 ] MRCPass - 2010 May

A 60 year-old man is admitted with
pain, weakness and numbness in his right
foot. He has had long standing lower back pain
but the symptoms of weakness and numbness
only started two weeks ago.

On examination, there was weakness of all
movements at the right ankle, an absent right

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ankle jerk and sensory impairment on lateral
aspect of the sole of the right foot. There was
plantar flexion with the babinski reflex.

Where is the likely site of the lesion?

1- Femoral nerve

2- Lumbosacral plexus

3- Obturator nerve

4- Sciatic nerve

Answer & Comments

Answer: 4- Increased sodium reaching the
collecting ducts

The two mechanisms of hypokalaemia cause
by the thiazide (Bendroflumethiazide) are
increased sodium reaching the collecting ducts
and activation of the renin-angiotensin-
aldosterone system

5- SI spinal root

Answer & Comments

Answer: 4- Sciatic nerve

Sciatic nerve palsy causes global weakness of
ankle due involvement of both of its branches:
tibial nerve (plantar flexion and inversion) and
common peroneal nerve (dorsiflexion and
eversion).

The right ankle jerk is also absent due to tibial
nerve involvement.

[ Q: 1927 ] MRCPass - 2010 May

A 45 year old patient who takes
bendroflumethiazide is noted to have a
potassium of 3.1 mmol/I.

What is the main mechanism causing
hypokalaemia in patients taking
bendroflumethiazide ?

1- Opening of potassium channels in the
proximal convoluted tubule

2- Decreased sodium reaching the distal
convoluted tubule

3- Decreased flow rate in the nephron
resulting in a decreased potassium gradient

4- Increased sodium reaching the collecting
ducts

5- Inhibition of renin-angiotensin-aldosterone
system

[ Q: 1928 ] MRCPass - 2010 May
A 75 year old woman presented with

a non healing ulcer on her right foot and was
admitted to hospital.

She has a temperature of 37.9 C. Blood
cultures on day 1 grew MRSA.

What antibiotics would you consider in
addition to vancomycin?

1- Co amoxiclav

2- Metronidazole

3- Rifampicin

4- Ciprofloxacin

5- Linezolid

Answer & Comments

Answer: 3- Rifampicin

Rifampicin and vancomycin are a good
combination for initial treatment of MRSA.

If this does not respond linezolid is a good
alternative.

[ Q: 1929 ] MRCPass - 2010 May

A 43 year old woman was admitted
to hospital with a several month history of
diarrhoea, malaise and weight loss. She was in
good health prior to the development of these
symptoms. On examination, she had mild
jaundice and looked thin. She had a distended
abdomen with shifting dullness to percussion.
Her blood tests show :

Hb 10.5 g/dl

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MCV 82 fl
WCC 8 x 10 9 /l
platelets 220 x 107 L
sodium 125 mmol/l
potassium 4.1 mmol/l
urea 11 mmol/l
creatinine 160 |imol/l,

ALT 95 (5-35) U/l
AST 115 (1-31) U/l
ALP 220(20-120) U/l
Bilirubin 30 (1-22) nmol/l
Albumin 28 (37-49) g/l

Carcinoembryonic antigen (CEA) 3.8 <2.5
ng/ml

Alpha-Fetoprotein (AFP) 55 < 44 ?g/L

CA125 - 38 (<35) U/ml

CA 19-9-250 (< 40) U/ml

CA 15-3-32 (< 29) U/mL

Prostate-Specific Antigen (PSA) 2 (< 4) ng/ml

Which one of the following is the likely primary
tumour?

1- Pancreas

2- Colorectal

3- Ovarian

4- Liver

5- Prostate

He develops multiple fleshy, red nodules on
the trunk and on the buttocks. The crops of
lesions are flat topped and papular. These
were treated and subsequently healed with
scarring, but the patient noticed further
lesions developing after a few months.

Which one of the following is most likely?

1- Molluscum contagiosum

2- Kaposi's sarcoma

3- Human papillovirus infection

4- Herpes zoster infection

5- herpes simplex infection

Answer & Comments

Answer: 2- Kaposi's sarcoma

Kaposi's sarcoma (KS) is a tumor caused by
Human herpesvirus 8 (HHV8) and frequently
found in patients with HIV infection.

Kaposi's sarcoma lesions may appear like
bruises but are papular. With time, they
darken. Scarring is common following
treatment with immunosuppressive drugs.

Molluscum contagiosum is a viral skin disease
characterised by firm, round, translucent,
umbilicated papules containing caseous
matter and peculiar capsulated bodies. It is
caused by a DNA virus of pox family. It can
appear with crops and can be treated with
cryotherapy. It tends to be self limiting and
does not scar.

Answer & Comments

[ Q: 1931 ] MRCPass - 2010 May

Answer: 1- Pancreas

n.j

A 62 year old man presents with a

The tumour markers are not specific to one
tumour but in this case the Ca 19.9 is highest,
and it is most strongly associated with
pancreatic cancer.

cough and chest x ray confirms that he has a
pneumonia.

Which one of the following is a bad prognostic
sign ?

[ Q: 1930 ] MRCPass - 2010 May
A 45 year old man is known to have

HIV.

1- Wbc >30 x 1071

2- Urea of 9 mmol/l

3- Temperature of 39 °C

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4- Age of 62

5- Consolidation on the CXR

Answer & Comments

Answer: 2- Urea of 9 mmol/l

The CURB - 65 score for assessment of severity
of pneumonia is tested here.

The criteria are:

■ Confusion of new onset (defined as an
AMT of 8 or less)

■ Urea greater than 7 mmol/l (Blood
Urea Nitrogen > 19)

■ Respiratory rate of 30 breaths per
minute or greater

■ Blood pressure systolic < 90 mmHg or
diastolic < 60 mmHg

age 65 or older

[ Q: 1932 ] MRCPass - 2010 May

A 30 year old lady is seeking genetic
advice. She has haemochromatosis and her
husband does not have any know ledge of
being affected.

What is the chance of a child carrying the
gene?

The HFE gene is located on short arm of
chromosome 6 at location. Approximately one
in ten people are carriers of the mutated
gene. It is thought that the HFE protein
functions to regulate iron absorption by
regulating the interaction of the transferrin
receptor with transferrin.

In this case, as the mother is homozygous for
the gene as it is autosomal recessive and she
has the disease. This means that all of her off
spring will be carriers of the gene.

[ Q: 1933 ] MRCPass - 2010 May

A 20 year old woman has been
referred with polyuria and polydipsia. She
mentions that she has had the symptoms for 2
months. Upon investigation the following
results were found.

sodium 148 mmol/l

potassium 4.5 mmol/l

urea 4 mmol/l

creatinine 78 |imol/l

Glucose: 5.5 mmol/l

Plasma Osmolality 308 (280-300) mmol/kgw
ater

Urine Osmolality . 90 (50-1200) mmol/kg
What is the diagnosis?

1- Addison's disease

1 - 0 %

2- Diabetes mellitus

2- 1 in 50

3- 1 in 100

4- 1 in 400

5- 100%

Answer & Comments

Answer: 5-100%

The inheritance of the HFE gene in
haemochromatosis is autosomal recessive.

3- Psychogenic polydipsia

4- Diabetes insipidus

5- SIADH

Answer & Comments

Answer: 4- Diabetes insipidus

Diabetes insipidus usually presents with thirst
and polyuria.

This is due to a lack of anti diuretic hormone
(ADH) action. Despite drinking a lot, water loss
leads to hypernatraemia and high plasma

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osmolality. The inappropriately low urine
osmolality is due to an inability to reabsorb
water (or concentrate urine). A lack of ADH
production is termed cranial diabetes
insipidus (e.g. pituitary tumour) and a lack of
response to ADH is termed nephrogenic
diabetes insipidus (e.g. action of drugs on the
kidney).

In contrast, a patient with psychogenic
polydipsia would not have high plasma
osmolalities and hypernatraemia (rather
would be hyponatraemic). A patient with
SIADH would not typically give a history of
polydipsia and polyuria.

[ Q: 1934 ] MRCPass - 2010 May

A 30 year old lady was admitted to
hospital by a concerned neighbour. She
complains of seeing spider's crawling all over
her body and she was disoriented. On
examination, she was tremulous and looked
very restless. She had a wide based, unsteady
gait.

What is the diagnosis?

1- Hyponatraemic encephalopathy

2- Schizophrenia

3- Benzodiazepine withdrawal

4- Delirium Tremens

5- Wernicke's encephalopathy

[ Q: 1935 ] MRCPass - 2010 May

A 63 year old man presents with
central crushing chest pain.

Which one of the following features is most
likely to be associated aortic dissection?

1- Jaw pain

2- Lower limb neurological deficit

3- Severe hypertension

4- Gas under the diaphragm on the chest x ray

5- Anaemia

severe

Answer & Comments

Answer: 3- Severe hypertension

Severe hypertension, aortic aneurysm and
connective tissue disorders (e.g. Marfan
syndrome) are predisposing factors to aortic
dissection. The nature of the pain can vary
significantly - epigastric pain, tearing pains,
back pains and even dull pains can occur.

[ Q: 1936 ] MRCPass - 2010 May

A 18 year old patient had a
continuous murmur and was suspected to
have patent ductus arteriosus.

What is the nature of the pulse likely to be?

1- Jerky

2- Bisferiens

Answer & Comments

Answer: 4- Delirium Tremens

This patient's history of disorientation,
agitation and hallucination fits delirium
tremens best.

If she was significantly confused rather than
having hallucinations, then alcoholic
(Wernicke's) encephalopathy should be
considered.

3- Dicrotic

4- Slow rising

5- Collapsing

Answer & Comments

Answer: 5- Collapsing

With a patent ductus arteriosus, the pulse
may be collapsing in nature if there is a large
shunt.

Other signs include a continuous or machinery
murmur is best heard at the upper left sternal
border or left infraclavicular area, and there

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may be signs of pulmonary hypertension (loud
second heart sound).

[ Q: 1937 ] MRCPass - 2010 May

A 25-year-old man presented with an
enlarged inguinal lymph node with night
sweats, and the most likely clinical diagnosis is
Hodgkin's lymphoma. A biopsy has been
taken.

Which of the following findings on histology
confers the best prognosis in Hodgkin's
lymphoma?

1- Lymphocyte depleted

2- Lymphocyte predominant

3- Mixed cellularity

4- Nodular sclerosing

5- Non-Hodgkin's changes

Answer & Comments

Answer: 2- Lymphocyte predominant

Hodgkin's lymphoma is a malignant
proliferation of the lymphoid system and is
characterised by the presence of Reed-
Sternberg cells on histological examination.

In order of good prognosis to worst, the
histology types are - lymphocytic predominant
> nodular sclerosis > mixed cellularity >
lymphocytic depletion.

The best prognosis is with lymphocyte
predominant histology and lymphocyte
depleted has the worst.

examination, he walks with a wide based gait
and has an MMSE score of 18 / 30.

Of the following which is the most likely
diagnosis?

1- Meningovascular syphilis

2- Normal pressure hydrocephalus

3- Syringomyelia

4- Wernicke-Korsakoff syndrome

5- Alzheimer's disease

Answer & Comments

Answer: 2- Normal pressure hydrocephalus

Normal pressure hydrocephalus (NPH) is a
clinical symptom complex characterized by a
triad of symptoms which are: abnormal gait,
urinary incontinence, and dementia.

Is a form of communicating hydrocephalus in
which the intracranial pressure, as measured
by lumbar puncture, is normal or
intermittently raised.

[ Q: 1939 ] MRCPass - 2010 May

A 45 year old patient presents with
proximal muscle weakness, particularly in the
lower limbs. She has a heliotropic rash around
the eyes and also has Gottron's papules.

Which one of the following antibodies is most
strongly associated?

1- Sm

2- Ro

3- Jo-1

[ Q: 1938 ] MRCPass - 2010 May

A 55-year-old man has drunk six
units of alcohol a day for most of his adult life.

He was found wandering the street and
appears confused. He was brought into
hospital for assessment. A friend gives a
history that he has worsening symptoms of
difficulty walking, headaches and urinary
incontinence for the past ten months. On

4- SCL-70

5- DsDNA

Answer & Comments

Answer: 3- Jo-1

The diagnosis is dermatomyositis.

Anti Jo-1 antibody is associated with acute
onset myositis, particularly dermatomyositis.

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The limb girdle or proximal muscles are most
severely affected in both polymyositis and
dermatomyositis.

^ [ Q: 1940] MRCPass-2010 May

* A 46 year old man is known to have
ulcerative colitis which was diagnosed 10
years ago. Over the last two months he has
right upper quadrant discomfort and noticed
to have jaundice. He was referred to the
gastroenterology outpatients for assessment.

Investigations performed showed these
results: Ultrasound showed a dilated intra and
extrahepatic ducts with beaded appearances.

Blood tests results:

ALT 120 (5-35) U/l

AST 90(1-31) U/l

ALP 850 (20-120) U/l

GGT 250 (4-35) U/l

Bilirubin 75 (1-22) pmol/l

Albumin 38 (37-49) g/l

What is the likely diagnosis?

1- Focal nodular hyperplasia

2- Primary sclerosing cholangitis

3- Hemangioma

4- Cholecystitis

5- Hepatocellular carcinoma

Primary sclerosing cholangitis is a disease of
unknown aetiology characterised by chronic
inflammation and fibrosis of the bile duct. It is
associated with cholangiocarcinoma, a cancer
of the biliary tree, and the lifetime risk for PSC
sufferers is 10-15%. As many as 5% of patients
with ulcerative colitis may progress to develop
primary sclerosing cholangitis and
approximately 70% of people with primary
sclerosing cholangitis have ulcerative colitis.

[ Q: 1941 ] MRCPass - 2010 May

A 28 year old lady had amenorrhoea
over the last 2 months after discontinuing use
of an oral contraceptive pill.

She has recently been doing vigorous exercise.

Which one of the following is most likely?

1- Premature ovarian failure

2- Panhypopituitarism

3- Adrenal tumour

4- Polycystic ovary disease

5- Amenorrhoea due to stopping OCP

Answer & Comments

Answer: 5- Amenorrhoea due to stopping OCP

Post-pill amenorrhoea occurs in some women
after stopping the combined oral
contraceptive pill.

Answer & Comments

Answer: 2- Primary sclerosing cholangitis

This usually settles spontaneously three
months after discontinuing the pill. Excessive
exercise is another cause of amenorrhoea.

The cholestatic picture along with
inflammatory lesion seen on the ultrasound
hints tow ards either Sclerosing cholangitis or
associated with ulcerative colitis.

Narrowing of the bile duct lumen usually
occurs throughout the biliary tree. Less
commonly, changes are confined to the intra-
hepatic or extra-hepatic ducts.

[ Q: 1942 ] MRCPass - 2010 May
Which one of the following is broken

down to Glucose and Galactose?

1- Maltose

2- Sucrose

3- Fructose

4- Mannose

5- Lactose

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Answer & Comments

Answer: 5- Lactose

Lactose is broken down into glucose and
galactose by an enzyme called lactase.

Answer & Comments

Answer: 3- Tumour suppressor

The BRCA genes belongs to a class of genes
known as tumor suppressor genes.

[ Q: 1943 ] MRCPass - 2010 May

A study assessed a statin tablet
compared to placebo for stroke prevention
over 2 years.

There were 10% of patients developing stroke
in the group taking a tablet and 20% in the
carotid endarterectomy group developing a
stroke.

What is the number needed to treat over 1
year to prevent 1 death?

1- 1

BRCA1 is expressed in the cells of breast and
other tissue, where it helps repair damaged
DNA, and destroy the cell when DNA can't be
repaired. If BRCA1 itself is damaged, the
damaged DNA can let the cell duplicate
without control, and turn into a cancer

[ Q: 1945 ] MRCPass - 2010 May

A 17 year old female was admitted

with acute severe asthma.

Which feature would make you think it is life
threatening?

2- 10

3- 20

4- 100

5- 1000

Answer & Comments

Answer: 2-10

NNT is defined as number needed to treat to
prevent 1 death.

The way to work this out is 1 divided by
absolute risk reduction (Experimental event
rate - control event rate). Hence 1 / (ARR) is 1
/ 10% which is 10.

[ Q: 1944 ] MRCPass - 2010 May

Which role does the BRCA gene play
in the DNA of tumour cells?

1- Telomerase inhibitor

2- Homeobox

3- Tumour suppressor

4- Tyrosine kinase

5- Cyclic AMP second messenger

1- PH of 7.40

2- Pa02 of 8.4

3- PaC02 of 5.5

4- RR 30

5- PEFR < 35% of predicted

Answer & Comments

Answer: 5- PEFR < 35% of predicted

The results show a normal pH, low p02,
normal C02 and high respiratory rate.

The most important predictors will be
significantly low Peak flow rate as in this case,
or Type II respiratory failure (high C02) with
respiratory acidosis.

^ [ Q: 1946 ] MRCPass - 2010 May

# A 65 year old man is admitted for
investigation of jaundice and anorexia for
several weeks. 6 weeks ago, he had completed
a course of medication which had been
prescribed by his GP.

Investigations reveal:

Albumin 40 g/L (37-49)

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Bilirubin 260 umol/L (1-22)

AST 80 iu/L (5-35)

Alkaline Phosphatase 430 iu/l (50-110)

Abdominal ultrasound reveals gallstones but
no evidence of cholecystitis.

Which drug is most likely to cause the
presentation?

1- Allopurinol

2- Augmentin

3- Amiodarone

4- Pravastatin

5- Ibuprofen

Answer & Comments

Answer: 2- Augmentin

The blood results are consistent with
cholestatic jaundice as there is significantly
elevated bilirubin and ALP.

Co-amoxiclav (augmentin) is a well known
cause of this.

Other drugs includes gold, nitrofurantoin,
anabolic steroids, chlorpromazine,
prochlorperazine, cimetidine, erythromycin
and estrogen.

[ Q: 1947 ] MRCPass - 2010 May

A 70 year old man is admitted to
casualty with severe agitation, tremors and
ataxia. He is known to be on an
antidepressant previously. Currently he
smokes 40 cigarettes a day and drinks 20 units
of alcohol per day.

What drug should be given for sedation?

1- Haloperidol

2- Diazepam

3- Chlorpromazine

4- Chlordiazepoxide

5- Propofol

Answer & Comments

Answer: 4- Chlordiazepoxide

Chlordiazepoxide is a benzodiazepine used to
control symptoms of alcohol withdrawal.

[ Q: 1948 ] MRCPass - 2010 May

A 19 year old female med student
performs valsalva's maneourve for a class
demonstration.

During the manoeuvre , what is the initial
physiological mechanism to occur?

1- Reduced stroke volume

2- Fall in cardiac output

3- Decrease in heart rate

4- Increase in systolic arterial blood pressure

5- Reduced venous return

Answer & Comments

Answer: 4- Increase in systolic arterial blood
pressure

A valsalva manoeuvre is forced expiration
against a held breath.

There is an initial blood pressure rise (increase
in stroke volume and cardiac output) as the
pressure in the chest forces blood

Following this, the increased pressure in the
chest reduces venous return and this also
leads to cardiac output to reduce, the heart
rate also decreases.

When the pressure is released (patient
exhales) there is then a slight blood pressure
drop The easiest way to appreciate this is the
graph below.

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—S ptateBP
* f'Jlo fu-.o I

[ Q: 1949 ] MRCPass - 2010 May

Which of the following is most likely
to be responsible for Ventricular tachycardia?

1- Hyponatremia

2- Hypokalaemia

3- Hypomagnesaemia

4- Hypophosphataemia

5- Hypothermia

Answer & Comments

Answer: 3- Hypomagnesaemia

Many of the options can cause VT / VF but as
an isolated cause the most likely is
hypomagnesaemia. As hypomagnesia is a
common cause of VT, a stat dose magnesium
sulphate is often given as initial treatment.

^ [Q: 1950] MRCPass-2010 May

* A patient presents with an inability
to abduct his right arm and has loss of
sensation over the right shoulder area.

Which dermatome is affected?

1- C3

2- C5

3- C7

4- C8

5- T1

Answer & Comments

Answer: 2- C5

The deltoid muscle is implicated here, as the
action is shoulder abduction and there is loss
of sensation over the C5 dermatome.

It is innervated by the axillary nerve (C5 and
C6).

[ Q: 1951 ] MRCPass - 2010 May

A 53-year-old woman presents with
periods of sweats and tremors which are
relieved by eating. She has gained
approximately 6 kg in weight in the last 2
years. Her BM is 4.5. Blood tests are: Hb 13
g/dl, MCV 78 fl, WCC 7 x 10 9 /l, platelets 200 x
10 9 /l, sodium 135 mmol/l, potassium 4.7
mmol/l, urea 5 mmol/l, creatinine 100 mmol/l,
TSH - 3.3 (0.3-4) mU/l, free T4 -20 (10-24)
pmol/l.

Whot is the most appropriate investigation?

1- 72 hour fast

2- CT scan of pancreas

3- MRI of the brain

4- Insulin C-peptide concentration

5- Oral glucose tolerance test

Answer & Comments

Answer: 1- 72 hour fast

This patient has symptoms suggestive of
hypoglycaemia which are relieved by
carbohydrate.

The likely cause is an insulinoma which is an
insulin secreting pancreatic tumour.

The best way of confirming the diagnosis is
with a 72 hour fast. During the fast, the
patient with an insulinoma may get episodes
of hypoglycaemia with measured
inappropriately high insulin C peptide
(endogenous insulin).

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Measurement of C-peptide is useful in
excluding factitious hypoglycaemia from self
injection of insulin. Insulin preparations do not
contain C-peptide.

pancreatitis such as pseudocysts) and ERCP
(showing chronic ductal changes) with some
advanced centres able to offer measurement
of pancreatic enzyme production (protease,
amylase, lipase).

^ [Q: 1952] MRCPass-2010 May

A 50 vear old ladv is assessed for

[ Q: 1953 ] MRCPass - 2010 May

longstanding abdominal symptoms. She

A 50 year old man has presented

describes chronic intermittent abdominal
pains which were moderate in intensity,
gripping in nature, localized in the middle of
the abdomen. She also had increased
frequency of stools up to 15 times a day. The
stool was brownish yellow in color, sticky and
oily, difficult to flush but devoid of blood or
mucus. Typically the abdominal pain was
relieved after passing the stool.

What is the best investigation to confirm the
diagnosis?

1- Duodenal biopsy

2- Liver biopsy

3- Tumour markers

4- Faecal fat

with assessment of shortness of breath and
wheezing. He works as a spray paint worker
and gives a history of feeling more breathless
during work. The symptoms improve during
the weekend. The GP refers her to the
respiratory clinic for assessment.

What investigation is most appropriate to
diagnose occupational asthma?

1- Measure peak flows over 2 weeks

2- Serial peak flow measurements at home
and work

3- Skin prick tests to isocyanates

4- Lung function test

5- IgE levels

5- Faecal elastase

Answer & Comments

Answer: 5- Faecal elastase

This patient has steatorrhoea and a diagnosis
of chronic pancreatitis.

Assays of fecal chymotrypsin and human
pancreatic elastase 1 are useful in confirming
advanced chronic pancreatitis with exocrine
insufficiency. To check for pancreatic exocrine
dysfunction, the most sensitive and specific
test is the measurement of fecal elastase,
which can be done with a single stool sample.
Faecal fat analysis can also be useful but less
convenient as it requires measurement of
fecal fat excretion over 24hr on a lOOg fat
diet.

Other useful tests are CT Scan demonstrating
calcification or complications of chronic

Answer & Comments

Answer: 2- Serial peak flow measurements at
home and work

Lung function tests and reversibility will help
to confirm asthma.

For diagnosis of occupational asthma, serial
measurements of peak expiratory flow rate at
home and at work: this is often the most
appropriate first step.

Measurements should be made every two
hours from waking to sleeping for four weeks,
keeping treatment constant and documenting
times at work. There should be at least 3
consecutive work days and 3 days aw ay from
work included in the measurements, (as per
Guidelines from the British Occupational
Health research on Occupational Asthma).

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[ Q: 1954 ] MRCPass - 2010 May

A 46 year old man has been to India
for 3 months, and returned 4 months ago. He
presents complaining that for 6 months, he
has had chronic diarrhoea with no blood. He
has been previously well with no
gastroenterological problems.

3- Hypoglycaemia

4- Steroid induced psychosis

5- Depressive psychosis

Answer & Comments

Answer: 4- Steroid induced psychosis

Which one of the following is the most likely
infection?

1- Yersinia

2- Giardia

3- E coli

The incidence of steroid associated cognitive
changes including psychosis are high
particularly when high dose steroids (e.g.
dexamethaxone) are used prior to or as part
of chemotherapy.

4- Salmonella

5- Campylobacter

Answer & Comments

Answer: 2- Giardia

Giardiasis (Giardia lamblia infection) often
causes chronic diarrhoea which is non-bloody.

This is prevalent in many countries. Symptoms
might last for up to 6 weeks and are those of
diarrhoea with some abdominal pains.

Salmonella, shigella and Campylobacter often
cause bloody diarrhoea.

Yersinia infection is a type of zoonosis
(infection from animal reservoir), although it
can cause fevers and abdominal symptoms,
there is no history in this case to suggest a
zoonosis.

[ Q: 1956 ] MRCPass - 2010 May

A 52 year old man has had several
previous episodes of knee joint effusions. He
presents with a swollen right knee. He was
apyrexial on admission. The knee was
aspirated on admission and serous fluid was
extracted.

Microscopy and gram stain of the fluid
showed no organisms.

2 days later the patient's knee sw elled up
again and he returned to hospital. However,
he complained of more pain and had a
temperature of 38°C. Blood tests revealed a
raised white cell count and CRP.

What should be done?

1- Repeat aspiration

2- Arthroscopy with washout

3- Intravenous antibiotics

[ Q: 1955 ] MRCPass - 2010 May

A 63 year old man who has been
diagnosed with a glioma is commenced on
chemotherapy. 4 days later, he begins to
behave strangely, and is noticed to become
increasingly agitated. He also has suicidal
ideation.

Which one of the following is most likely?

1- Vincristine encephalitis

2- Hyponatraemia

4- X ray of the knee

5- MRI of knee joint

Answer & Comments

Answer: 1- Repeat aspiration

Infection after knee aspiration is very
uncommon (0.01% incidence).

However, this patient's history of pyrexia does
suggest the possibility, hence repeat
aspiration and sending fluid for microscopy

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and culture is sensible. If the provisional
results suggest infection, or of there are other
clinical suggestions of bacteraemia or sepsis
then the patient should be treated with
antibiotics. Septic arthritis can be treated with
arthroscopy and washout, but usually in
complicated cases e.g. with prosthesis or if a
patient does not respond to medical therapy.

[ Q: 1957 ] MRCPass - 2010 May

A 62 year old man has discomfort in
the left ankle for 2 days. Several weeks ago he
had been on a course of antibiotics. He
presented to the emergency department with
mild, nonpitting edema of the left calf and
ankle, and pain on plantar flexion. A Doppler
study failed to detect a thrombus, and there
was no radiologic evidence of a fracture. The
patient was diagnosed with a muscle strain
and achilles tendon rupture.

Which drug may hove coused this?

1- Ciprofloxacin

2- Metronidazole

3- Amoxicillin

4- Nitrofurantoin

5- Gentamicin

2- 1 month before Surgery

3- Several hours before Surgery

4- 1 week after Surgery

5- One month after surgery

Answer & Comments

Answer: 2-1 month before Surgery

Pneumovax should be given at least two
weeks before splenectomy, hence in this
situation a month before is the best answer.

[ Q: 1959 ] MRCPass - 2010 May

Which ion / channel is primarily
responsible for repolorisotion phase in the
cardiac cycle?

1- Sodium

2- Sodium Calcium

3- Phosphate

4- Magnesium

5- Potassium

Answer & Comments

Answer: 5- Potassium

Answer & Comments

Answer: 1- Ciprofloxacin

Disruptions of tendons in adults, including
rupture, have been reported in association
with fluoroquinolones (ciprofloxacin).

The Achilles tendon is the site most frequently
associated with such adverse outcomes.

[ Q: 1958 ] MRCPass - 2010 May

A patient is about to undergo a
splenectomy.

Depolarisation and repolarisation refer to
neuronal conduction or cardiac electrical
activity.

The action potentials produced by
depolarization (due to Na+ ions moving into
cell), leads to release of Ca2+ ions which lead
to contraction of cardiac muscle, followed by
repolarization (K+ ions moving into cell).

[ Q: 1960 ] MRCPass - 2010 May

A 47 year old man presented with a
history of hemoptysis for two months and he
had lost 5 kg of weight.

When should pneumococcal vaccine be given
in relation to splenectomy?

1- 1 week before Surgery

He gives a past history of tuberculosis 20 years
ago which was treated with drugs for 6
months. On physical examination, chest

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auscultation revealed decreased air entry on
right upper lung field. Chest X ray showed a
cavitating lesion with dense shadows in right
upper lobe. Investigations show that the
sputum culture was negative for acid fast
bacilli and IgG antibodies for A fumigatus were
positive.

What is the most likely couse?

1- Bronchogenic carcinoma

2- Reactivation of tuberculosis

3- Aspergilloma

4- Invasive aspergillosis

5- Lung abscess

Answer & Comments

Answer: 3- Aspergilloma

An aspergilloma is is a tangled mass composed
of hyphae, fibrin, and inflammatory cells, that
lies free in the lung cavity.

Aspergillomata may form in cavities produced
by previous lung diseases e.g. tuberculosis,
abscesses, or areas of pulmonary infarction. It
is usually caused by A. fumigatus. The most
common symptom of aspergillomas is
haemoptysis. Aspergillus precipitin antibody
test results (ie, for IgG) are usually positive.

50% of the UK population are slow
acetylators, i.e. have a deficiency of the
enzyme N acetyltransferase.

Acetylator status is important in determining
drug response and drug toxicity, e.g. slow
acetylators are more at risk of developing drug
induced lupus, the three commondest drugs
implicated are hydralazine, isoniazid and
procainamide.

^ [ Q: 1962 ] MRCPass - 2010 May

n ~--—

# A 35 year old male patient was
admitted into the emergency department
complaining of double vision and dizziness.
There was no relevant past medical history
but he described a coryzal illness 2 weeks ago.
On examination, he was short of breath at
rest. He had reduced eye movements, in
particular abduction in both eyes.

Visual acuity was normal and there were no
other cranial nerve deficits. Tone was normal
in both upper and lower limbs. Power was
reduced in the distal modalities of the arms
and legs. He had flaccid reflexes throughout
and plantars were downgoing.

Whot is the likely diagnosis?

1- Multiple sclerosis

2- Bilateral cerebrovascular accidents

[ Q: 1961 ] MRCPass - 2010 May

Which one of the following drugs is
likely to couse on adverse effect among slow
acetylators?

1- Amoxicillin

2- Trimethoprim

3- Hydralazine

4- Minoxidil

5- Ramipril

Answer & Comments

Answer: 3- Hydralazine

3- Miller-fisher syndrome

4- Transverse myelitis

5- TB meningitis

Answer & Comments

Answer: 3- Miller-fisher syndrome

Miller Fisher Syndrome is a peripheral
neurological condition (variant of acute
demyelination or Guillain Barre syndrome),
mostly associated with respiratory or digestive
infections.

The average time for neurological symptoms
to appear after infection is 1-2 weeks. It is
considered to be initiated by a autoimmune

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process. The typical triad for this syndrome
includes ophthalmoplegia, ataxia, and
arreflexia. As with Guillain Barre syndrome, IV
Ig should be considered for treatment and the
patient should be monitored closely for
deterioration in respiratory function.

[ Q: 1963 ] MRCPass - 2010 May

A 30-year-old woman presents with
red, raised, itchy lesions that involve her
entire body, including her face.

These lesions come and go at the different
parts of the body over the last 2 days.

What treatment should be given?

1- Dapsone

2- Cetirizine

3- Prednisolone

4- Diprobase

5- Fluconazole

Answer & Comments

Answer: 2- Cetirizine

The itchy red skin lesions which come and
disappear are consistent with urticaria.

The patient should be given an antihistamine
such as cetirizine. If the reaction is severe and
there are signs of anaphylaxis then steroids
should be given in addition.

Answer & Comments

Answer: 1- Acalculia

Lesions of parietal lobe include apraxias,
neglect, astereognosis (unable recognise an
object by feeling it) visual field defects
(typically homonymous inferior

quadrantanopia).

They may also cause alcalculia (inability
perform mental arithmetic). Lesions of
temporal lobe cause visual field defects
(typically homonymous superior

quadrantanopia), Wernike's (receptive)
aphasia, auditory agnosia, memory
impairment.

[ Q: 1965 ] MRCPass - 2010 May

A 40-year-old female presented with
an erythematous annular patch with central
clearing on her left forearm following a tick
bite. The patient mentioned she had recent
onset of intermittent joint pains and
asymmetry of her face. On examination, she
was pyrexial and had bilateral 7th cranial
nerve palsy.

What is the preferred drug?

1- Prednisolone

2- Doxycycline

3- Tazocin

4- Ceftriaxone

^ [ Q: 1964 ] MRCPass - 2010 May

# A 60 year old man was found to have
a parietal lobe stroke.

Which one of the following is a sign which may
be present?

1- Acalculia

2- Homonymous superior quadrantanopia

3- Perseveration

4- Primitive reflexes

5- Wernicke's (receptive) aphasia

5- Gentamicin

Answer & Comments

Answer: 4- Ceftriaxone

Lyme Disease (LD) is a multisystem disease
affecting the nervous system, skin, joints, and
heart.

Erythema migrans, the characteristic
dermatologic lesion of LD, is described here.
Early localized disease manifests within 3-30
days presenting with erythema migrans,

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myalgia, fatigue, headache, fever,
lymphadenopathy, and arthralgia.

This usually occurs 30 to 120 days post¬
infection and is characterized by erythema
migrans , fatigue, lymphadenopathy,
conjunctivitis, neck pain, cardiac
abnormalities, radiculoneuritis, arthritis, and
CNS manifestations.

Many of the inital signs in tricyclic
antidepressant (TCA) overdose are associated
to the anticholinergic effects of TCAs such as
dry mouth, blurred vision, urinary retention,
constipation, dizziness and vomiting.

In a patient who is acidotic who is at risk of
cardiac arrhythmias and seizures, serum
bicarbonate is recommended.

First-line treatment for early disease is
doxycycline (100 mg PO twice a day for 14
days) or amoxicillin unless there is
neurological involvement.

In this case, there is neurological involvement
(neuroborreliosis) hence the preferred
treatment would be intravenous ceftriaxone.
There remains some controversy about
whether doxycycline is just as effective.

[ Q: 1966 ] MRCPass - 2010 May

A 25 year-old woman with a history
of depression is brought to the hospital with
decreased conscious level and a brief seizure.
She had taken an overdose of tricyclic
antidepressants 12 hours prior. Her GCS is
12/15, she is tachycardic to 120 bpm and her
blood pressure is 96/62 mmHg. She appears
flushed and her skin is dry. A blood gas shows:

pH -7.15

p02 -13.3 kPa

pC02 -3.5 kPa

base excess - negative 8.5

What should be the management?

1- Gastric Lavage

2- Charcoal

[ Q: 1967 ] MRCPass - 2010 May

A 30 year old lady ate in a Chinese
restaurant before presenting with vomiting
and diarrhoea 4 hours later. She continued to
have the symptoms on the following day.

What is the most likely organism which is
responsible?

1- Campylobacter

2- Escherichia coli

3- Bacillus cereus

4- Salmonella

5- Giardia lamblia

Answer & Comments

Answer: 3- Bacillus cereus

B. cereus food poisoning results from the
ingestion of preformed enterotoxins,
producing predominantly vomiting and
diarrhea. It is implicated in food takeaw ays
when rice is re-heated. The vomiting form is
most often associated with ingestion of a heat
stable toxin from contaminated rice, while the
diarrheal form is most often associated with
ingestion of a heat labile toxin from
contaminated meat or vegetables.

3- 8.4% bicarbonate infusion

4- Naloxone infusion

5- Flumazenil infusion

Answer & Comments

Answer: 3- 8.4% bicarbonate infusion

[ Q: 1968 ] MRCPass - 2010 May

A 51-year-old woman with a
longstanding medical history of rheumatoid
arthritis was admitted to hospital because of
nausea and leg sw elling. She said that she had
worsening ankle sw elling over the last two
years.

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She was previously on gold injections and over
the last few months she took regular
ibuprofen because of worsening joint pains.

Blood results reveal : sodium 137 mmol/I,
potassium 4.5 mmol/I, urea 25 mmol/l,
creatinine 290 mmol/l. Urine dipstick

shows protein +++, blood +.

Whot is the most likely couse of renoi failure?

1- Interstitial nephritis

2- Papillary necrosis

3- Acute tubular necrosis

4- Renal artery stenosis

5- Amyloidosis

1- Bundle branch block

2- Supraventricular tachycardia

3- Ventricular tachycardia

4- Cerebral embolism

5- Acute Myocardial infarction

Answer & Comments

Answer: 3- Ventricular tachycardia

This patient had a syncopal event and also a
history of ischaemic heart disease.

The ECG changes are not specific for
myocardial infarction, and in this case the
clinical history suggests VT is most likely.

Answer & Comments

Answer: 5- Amyloidosis

The most common renal disorders associated
with RA are membranous nephropathy,
secondary amyloidosis, a focal, mesangial
proliferative glomerulonephritis, rheumatoid
vasculitis, and analgesic nephropathy.

NSAID nephropathy may lead to acute tubular
necrosis, interstitial nephritis and papillary
necrosis. However the history of ankle sw
elling and proteinuria suggests Amyloidosis. In
rheumatoid arthritis secondary (AA)
Amyloidosis is associated, and it presents
typically with impaired renal function and
proteinuria.

^ [ Q: 1970 ] MRCPass - 2010 May

fi -

# A 55 year old man presented with
severe retrosternal chest pain. He has history
of hypertension and diabetes.

His ECG shows anterior wall myocardial
infarction with ST elevation in leads VI to V4.
He has been given Aspirin, Clopidogrel and
Fondaparinux and is currently awaiting
angiography. However, he continues to have
chest pains.

Which other drug should be given?

1- Tissue plasminogen activator

2- Streptokinase

3- Statin

^ [ Q: 1969 ] MRCPass - 2010 May

II -

# A 65 year old man was admitted
following a collapse with loss of
consciousness. A history from a friend
revealed that he had a previous myocardial
infarction and was currently on several cardiac
medications. An ECG showed >2mm ST
elevation in Leads Vl-3 with no reciprocal
changes and there was no evidence of q
waves.

Whot is the most likely diagnosis?

4- ACE-inhibitor

5- GIIBIIIA inhibitor

Answer & Comments

Answer: 5- GIIBIIIA inhibitor

This patient is unstable and should be
considered for a GIIBIIIA inhibitor such as
tirofibran whilst awaiting coronary
angiography.

Abxicimab, another GIIBIIIA inhibitor, is also
frequently used prior to angioplasty.

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Thrombolysis is not indicated if the patient is
going to undergo angiography because the
risk of bleeding is high.

omeprazole twice a day and has been
compliant. A repeat endoscopy now shows
two oesophageal ulcers.

[ Q: 1971 ] MRCPass - 2010 May

A 60 year old woman presented with
a 10-year history of increasing stiffness and
immobility which have led to multiple falls.
She had had some difficulty in fine finger
movement and urinary incontinence. On
examination she had a lying BP of 130 / 80
mmHg and a standing BP of 90 / 60 mmHg.
She had a mask like facies, bradykinesia, and
resting a tremor in both of her hands. There
was also short-term memory loss.

What is the diagnosis?

1- Lewy body dementia

What is the appropriate investigation?

1- Barium enema

2- insulin tolerance test

3- H. pylori serology

4- Colonoscopy

5- Gastrin levels

Answer & Comments

Answer: 5- Gastrin levels

Diarrhea and recurrent gastric ulceration is
common with Zollinger Ellison syndrome
(gastrinoma).

2- Alzheimer's disease

3- Parkinson's disease

4- Multi system atrophy

5- Progressive supranuclear palsy

There would be demonstrable high fasting
plasma gastrin levels. Gastrinomas may occurs
as part of a multiple endocrine neoplasia
syndrome type 1.

Answer & Comments

Answer: 4- Multi system atrophy

Multi system atrophy (Shy drager syndrome)
consists of a cluster of several features:

Parkinsonism (increased tone, bradykinesia,
resting tremor)

Autonomic dysfunction (postural hypotension,
urinary incontinence, constipation)

Ataxia (leading to falls)

^ [ Q: 1973 ] MRCPass - 2010 May

# A 54-year-old woman with history of
uncontrolled hypertension presented to the
eye clinic with sudden vision loss in the right
eye. Ophthalmologic exam showed visual
acuity of hand motion in the right eye and 6/6
in the left eye. Pupil exam showed sluggish
right pupil with relative afferent papillary
defect, and a reactive pupil on the left.

Examination of the right eye showed retinal
haemorrhages and extensive areas of capillary
non-perfusion.

Unlike Parkinson's disease, L-dopa is not What is the diagnosis?

effective and treatment is mainly supportive. . ~,

y 1- Glaucoma

[ Q: 1972 ] MRCPass - 2010 May

A 42 year old man presents with
frequent diarrhoea and upper abdominal
pains.

He had a partial gastrectomy 6 months ago for
upper Gl bleeding. He is now on high dose

2- Retinal vasculitis

3- Central retinal vein thrombosis

4- Central retinal artery occlusion

5- Malignant hypertension

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Answer & Comments

Answer: 3- Central retinal vein thrombosis

Clinically, central retinal vein thrombosis
presents with visual loss; the fundus may
show retinal hemorrhages, dilated tortuous
retinal veins, cotton-wool spots, macular
edema, and optic disc edema.

Major risk factors are hypertension, diabetes,
and atherosclerosis. Other risk factors are
glaucoma, syphilis, sarcoidosis, vasculitis,
hyperviscosity syndromes (multiple myeloma,
Waldenstrom's macroglobulinemia, and
leukemia), high homocysteine levels, sickle
cell, and HIV.

^ [ Q: 1974 ] MRCPass - 2010 May

£ .

* A 36 year old Caucasian female
presented with malaise, joint pains and
Raynaud's phenomenon for the last 6 months.
On physical examination she was afebrile and
had a supine blood pressure of 110/80mm Hg
Blood tests revealed:

Hb 11.5 g/dl, MCV85 fl

erythrocyte sedimentation rate of 80 mm/first
hour

antinuclear antibody (ANA) - strongly positive

antitopoisomerase I antibody (formerly anti
SCL-70 antibody) positive

normal C3 and C4

anti-DNA, anti-centromere, anti-RNP, anti-Ro
and La antibodies - negative

Whot other feature is likely to be present?

1- Proximal myopathy

2- Heliotrope rash

3- Calcinosis

4- Telangiectasia

5- Renal involvement

Answer & Comments

The patient is likely to have a diffuse form of
scleroderma.

The limited cutaneous form of scleroderma is
CREST syndrome (calcinosis, raynauds,
esophageal dysmotility, sclerodactyly and
telangiectasia).

The diffuse form of scleroderma is more
rapidly progressing and affects the skin
(cutaneous scleroderma) and one or more
internal organs, frequently the kidneys (renal
crisis), esophagus, heart (pulmonary
hypertension) and lungs (pulmonary fibrosis).

In diffuse scleroderma, antinuclear antibodies
are present in about 95% of patients.

Topoisomerase I antibodies (formerly Scl-70)
are present in approximately 30% of patients
with diffuse disease (absent in limited disease)
and are associated with pulmonary fibrosis.

Anticentromere antibodies are present in
about 60-90% of patients with limited disease
and are rare in patients with diffuse disease.

^ [ Q: 1975 ] MRCPass - 2010 May

f\ -

Which blood gas result may be an
analytical error?

1- PH 7.6, PaC02 - 2, P02 -13, Bicarbonate 30

2- PH 7.3, PaC02 - 7, P02 -10, Bicarbonate 14

3- PH 7.5, PaC02 - 8, P02 -10, Bicarbonate 14

4- PH 7.5, PaC02 - 6, P02 -12, Bicarbonate 26

5- PH 7.2, PaC02 - 9, P02 9, Bicarbonate 12

Answer & Comments

Answer: 3- PH 7.5, PaC02 - 8, P02 - 10,
Bicarbonate 14

The patient has a high C02 and low
bicarbonate which would suggest
uncompensated respiratory acidosis, hence
the pH shows an alkalosis which is too high to
fit the scenario.

Answer: 5- Renal involvement

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[Q: 1976] MRCPass - 2010
September

A 55 year old lady has known mitral valve
stenosis from rheumatic heart disease.

She presents with new symptoms of
breathlessness. Upon examination, which one
of the following signs would suggest that she
has mitrol regurgitation?

1- Displaced apex beat

2- Early diastolic murmur in the pulmonary
area

3- Right ventricular heave

4- V wave seen with the JVP

5- Opening snap

Answer & Comments

Answer: 1- Displaced apex beat

In mitral stenosis, the apex beat is classically
tapping in nature and not displaced.

Mitral regurgitation on the other hand, causes
ventricular strain and dilatation. Most of the
other signs described in the above options can
occur with pulmonary hypertension due to
significant mitral stenosis.

A 49-year-old woman has a history of
schizophrenia and is currently on haloperidol
(10 mg twice a day) and risperidone (1 mg
twice a day).

The atypical antipsychotic effect of risperidone
is due to its action on the:

1- Alpha adrenergic receptor

2- Adrenaline receptor

3- Acetylcholine receptor

4- Serotonin receptor

5- Dopamine 2 receptor

[Q: 1977] MRCPass-2010
September

Answer & Comments

Answer: 4- Serotonin receptor

Risperidone is an atypical antipsychotic drug
which has more pronounced serotonin
antagonism than dopamine antagonism.

It has actions at several 5-HT (serotonin)
receptor subtypes. The 'atypical' effects is due
to the effectiveness via the 5-HT2A receptor,
which reduces the extrapyramidal side effects
(EPS) experienced with the typical
neuroleptics due to the action on the
dopamine receptor.

A 40 year old man with diabetic nephropathy
and hemodialysis-dependent renal failure is in
clinic for evaluation of her blood results. She
had been found to have the following :
potassium 5.2 mmol/l, calcium 2.20 (2.25-2.7)
mmol/I, albumin 42 g/l, phosphate 1.55 (0.8-
8) mmol/l, parathyroid hormone (PTH) levels
over 220 pg/mL (normal <65 pg/mL).

What should be prescribed?

1- Calcium acetate

2- Cinacalcet

3- Alucaps

4- Alfacalcidol

5- Sando phosphate

[Q: 1978] MRCPass-2010
September

Answer & Comments

Answer: 1- Calcium acetate

This question refers to a patient with likely
secondary hyperparathyroidism and
hyperphosphataemia rather than

hyperparathyroidism being the main problem.

The most significant long-term complication of
chronic uncontrolled hyperphosphatemia is
the development of vascular calcifications.
Patients with secondary hyperparathyroidism

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usually have a low -normal calcium and
elevated parathyroid hormone (PTH).

Patients with tertiary hyperparathyroidism
may have hypercalcaemia along with a high
PTH level.

Phosphate binders can be used if
hyperphosphatemia persists despite dietary
phosphate restriction. These include calcium-
based phosphate binders such as calcium
carbonate, calcium acetate and non-calcium-
based phosphate binders such as sevelamer
hydrochloride. Calcium supplementation
should be limited to less than 2 g/day.

Cinacalcet is a calcimimetic which inhibits the
release of PTH. It is recommended in patients
with dialysis who have secondary
hyperparathyroidism and a very high PTH level
(800 pg/ml).

A 60 year old lady has pain in her knees,
shoulders, wrists and fingers. Examination of
her hands reveals multiple symmetrical small
joint involvement. The proximal and distal
joints were affected. Joint X rays show the
presence of osteophytes and
chondrocalcinosis. She is currently on
bendrofluazide and metformin tablets. A urate
level on admission was 420 (<380 pmol/l). The
rheumatoid factor was positive with a titre of
1:30.

What is the diagnosis?

1- Polyarticular gout

2- Calcium pyrophosphate deposition disease

3- Systemic lupus erythematosus

4- Haemochromatosis

[Q: 1979] MRCPass - 2010
September

The diagnosis would fit with a subcategory of
calcium pyrophosphate deposition disease,
which is Pseudoosteoarthritis often involves
the metacarpophalangeal (MCP) joints, wrists,
elbow s, and shoulders, joints unlikely to be
involved with primary osteoarthritis.

It affects the knees most commonly and can
involve the proximal interphalangeal (PIP)
joints and spine. Osteophytes and
chondrocalcinosis are a common radiological
finding in patients with a pseudoosteoarthritis
condition and usually are present along the
second and third metacarpal heads. In
addition, older individuals may have low -titer-
positive rheumatoid factor as in this case.

Pseudogout is one manifestation of calcium
pyrophosphate deposition disease, where
joint aspiration fluid might show rhomboid¬
shaped, positively birefringent crystals. This
case is less likely to be gout as it usually
affects the knee and big toe. In acute gout the
uric acid level is usually normal, so an early
urate level is not helpful.

[Q: 1980] MRCPass-2010
September

A 55 year old lady with COPD presents with
shortness of breath. She has nebulisers at
home but not homeoxygen. On admission, her
oxygen saturations were 88% and the nurse
asks how you would want oxygen given.

What should you recommend?

1- Nasal cannulae

2- Plain mask with non rebreathe bag

3- Plain mask only

4- Venturi mask

5- Humidified oxygen mask

5- Rheumatoid arthritis

Answer & Comments

Answer: 2- Calcium pyrophosphate deposition
disease

Answer & Comments

Answer: 4- Venturi mask

The venturi mask, also known as an air-
entrainment mask, delivers a known oxygen

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concentration to patients on controlled
oxygen therapy, this is particularly important
in COPD patients.

Venturi masks are considered high-flow
oxygen therapy devices. This is because
venturi masks are able to provide total
inspiratory flow at a specified FI02 to patients
therapy. The kits usually include multiple jets
in order to set the desired FI02 which are
usually color coded. In the UK, the colours and
respective delivery concentrations are; Blue
24%, White 28%, Yellow 35%, Red 40%, Green
60%).

A 24 year old lady was complaining of tremors
and sw eating for 6 weeks and referred for
assessment. She has lost 6 kg in weight. On
examination, she has tremors in the hands
and a palpable smooth goitre. An nuclear
medicine scan of the neck showed increased
and patchy uptake of radio isotope of the
thyroid glands. Following tests, she is
diagnosed with thyrotoxicosis. Laboratory
data confirmed the following results: free T4-
48 (10-24) pmol/l, TSH < 0.3 (0.3-4) mU/l,
antithyroid antibodies negative.

Whot is the definitive treatment?

1- Propranolol

2- Prednisolone

[Q: 1981] MRCPass - 2010
September

or technetium isotopes. Whilst antithyroid
drugs such as carbimazole or methimazole as
well as propanolol can be used for short term
treatment, the definitive treatment should be
either radioactive iodine or thyroid surgery.

[Q: 1982] MRCPass-2010
September

A 40-year-old woman complains of recurrent
migraine type headaches. The headaches have
been occurring every week, increasing in
intensity and are associated with flashing
lights. She was treated with paracetamol,
diclofenac and sumatriptan with little
improvement.

Which of the following medications would you
prescribe?

1- Pizotifen

2- Ergotamine

3- Propanolol

4- Verapamil

5- Sodium valproate

Answer & Comments

Answer: 3- Propanolol

The actual question did not specify whether
the medication was for acute treatment or
prophylaxis, but the way it was phrased
suggested that it asked for prophylaxis.

3- Thyroxine

4- Radioactive iodine

5- Carbimazole

Propanolol, verapamil and sodium valproate
can all be used for prophylaxis, and propanolol
is the most commonly prescribed.

Answer & Comments

Answer: 4- Radioactive iodine

This patient has toxic multinodular goitre with
features of thyrotoxicosis such as sweats,
palpitations, tremors and weight loss.

On nuclear imaging there is usually patchy
increased uptake of either radioactive iodine

A 25 year old lady presents with abdominal
pains and lethargy. She has a history of
diabetes and was on insulin.

Clinical examination was unremarkable and
she had an abdominal X ray which showed the
presence of renal calculi.

[Q: 1983] MRCPass-2010
September

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Investigations revealed the following:

arterial blood pH 7.30 (7.38-7.44)

serum bicarbonate 12.6 mmol/L (21-28
mmol/L)

sodium 146 (136-145 mmol/L)
potassium 2.8 (3.5-5mmol/L)
chloride 122 (98-106mmol/L)

Anion gap was 15 (normal 7-16 mmol/L)

Urine pH of 6.5 (normal range 5-9)

Whot is the likely diagnosis?

1- Multiple myeloma

2- Renal tubular acidosis type 1

3- Nephrotic syndrome

4- Homocystinuria

5- Porphyria

Answer & Comments

Answer: 2- Renal tubular acidosis type 1

The diagnosis of Type 1 RTA is based on the
findings of systemic acidosis, low bicarbonate,
hypokalemia, a normal anion gap and
relatively alkaline urine despite the acidosis.

Type 1 RTA can be familial with autosomal
dominant as the most common mode of
inheritance. Typical features of type 1 RTA are
osteomalacia and nephrocalcinosis.

^ [ Q: 1984 ] MRCPass - 2010

September

A 57 year old man had a myocardial infarction
and was transferred for coronary angiography.
A day following this, he developed red dusky
discoloration on the right foot and became
pyrexial. He had a femoral bruit on the right
side on examination. Eosinophilia was noted
on the blood tests and he had a creatinine of
650 umol/l.

Which one of the following is likely?

1- Baker's cyst

2- Compartment syndrome

3- Cellulitis

4- Cholesterol embolism

5- Anaphylactic reaction

Answer & Comments

Answer: 4- Cholesterol embolism

Cholesterol embolism should be suspected in
a patient with atherosclerotic disease who has
fever and distal ischaemia.

Eosinophilia strongly suggests

atheroembolization and is present in as many
as 80% of patients with cholesterol embolism
syndrome. The patient is also likely to have
cholesterol emboli to the kidneys causing
renal impairment.

Associated causes are Sjogren's syndrome,
SLE, rheumatoid arthritis, renal
transplantation and sickle cell anaemia.

Type II RTA is associated with disorders such
as cystinosis, galactosaemia,Wilson's disease,
multiple myeloma and Paroxysmal nocturnal
haemoglobinuria. The distal intercalated cells
function normally, so the acidemia is less
severe than dRTA and the urine can acidify to
a pH of less than 5.3.

[Q: 1985] MRCPass-2010
September

A 48-year-old Filipino man was first noted to
have hematuria 5 years ago. He complains of
noticing haematuria both at home and at
work several times a week. There are no other
symptoms. His blood pressure is 130 / 70
mmHg.

Urinalysis during that admission showed trace
proteinuria and 2+ blood on the urinary
dipstick. His blood tests show :

sodium 135 mmol/l

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potassium 4.5 mmol/l
urea 6 mmol/l
creatinine 80 |imol/l
What is the likely diagnosis?

1- Thin basement membrane disease

2- Focal segmental glomerulosclerosis

3- Minimal change disease

4- Transitional cell carcinoma

5- Post streptococcal glomerulonephritis

study failed to detect a thrombus, and there
was no radiologic evidence of a fracture. The
patient was diagnosed with a muscle strain
Achilles tendon rupture.

Which drug may have caused this?

1- Ciprofloxacin

2- Metronidazole

3- Amoxicillin

4- Nitrofurantoin

5- Gentamicin

Answer & Comments

Answer: 1- Thin basement membrane disease

Thin basement membrane disease (TBMD,
also known as benign familial hematuria and
thin basement membrane nephropathy) is,
along with IgA nephropathy, the most
common cause of asymptomatic hematuria.

The only abnormal finding in this disease is a
thinning of the basement membrane of the
glomeruli in the kidneys. It has a benign
prognosis.

Most patients with thin basement membrane
disease are incidentally discovered to have
microscopic hematuria on urinalysis. The
blood pressure, kidney function and the
urinary protein excretion are usually normal.
Mild proteinuria (less than 1.5 g/day) and
hypertension are seen in a small minority of
patients. Frank hematuria and loin pain should
prompt a search for another cause, such as
kidney stones or loin pain-hematuria
syndrome.

A 61 year old man has discomfort in the left
ankle was noted 2 days. Several weeks ago he
had been on a course of antibiotics. He
presented to the emergency department with
mild, nonpitting oedema of the left calf and
ankle, and pain on plantar flexion. A Doppler

[Q: 1986] MRCPass - 2010
September

Answer & Comments

Answer: 1- Ciprofloxacin

Disruptions of tendons in adults, including
rupture, have been reported in association
with fluoroquinolones (ciprofloxacin).

The Achilles tendon is the site most frequently
associated with such adverse outcomes.

[Q: 1987] MRCPass-2010
September

A 55 year old man has large spade-like hands
and finds that he is having to buy shoes of
increasing size in the last two years. On
examination of his visual fields, bitemporal
hemianopia was found.

Which one of the following tests should be
done?

1- Insulin tolerance test

2- Hydrocortisone curve

3- CT scan of the chest

4- Dexamethasone suppression test

5- Oral glucose tolerance test with growth
hormone

Answer & Comments

Answer: 5- Oral glucose tolerance test with
growth hormone

The case scenario suggests acromegaly.

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Growth hormone suppression during oral
glucose tolerance and elevated IGF-I levels
form the main diagnostic criteria in
acromegaly. IGF1 provides the most sensitive
and useful lab test for the diagnosis of
acromegaly. A single value of the Growth
hormone (GH) is not useful in view of its
pulsatality (levels in the blood vary greatly
even in healthy individuals). GH levels taken 2
hours after a 75 or 100 gram glucose
tolerance test are helpful in the diagnosis: GH
levels are suppressed below 1 ?g/L in normal
people, and levels higher than this cutoff are
confirmatory of acromegaly.

[Q: 1988] MRCPass - 2010
September

A 60 year old woman has recently had
lethargy and arthralgia. She was diagnosed as
having influenza infection, as there was an
outbreak in the area recently. She presents 1
week later with a cough and breathlessness.
On examination, she had bilateral crackles
audible on examination. CXR confirms bilateral
consolidation.

Which one of the following is most likely as a
co use?

1- Legionella

2- Mycoplasma

3- Streptococcus pneumoniae

4- Klebsiella

5- Staphylococcus aureus

Answer & Comments

Answer: 5- Staphylococcus aureus

Normal incidence of staph aureus pneumonia
is 2%, However this is significantly increased in
iv drug users and influenzae virus infections.

Post influenzae staph aureus pneumonia is
characterised by rapid clinical deterioration
with septicaemia.

[Q: 1989] MRCPass-2010
September

A 52-year-old man was admitted because of
progressive shortness of breath. He has been
a smoker of 5 cigarettes a day for the past two
years. He has a past medical history of
seropositive rheumatoid arthritis, diabetes
mellitus and hypertension. On examination
the fingers were clubbed and there were
bilateral basal crepitations. Lung function tests
showed:

forced expiratory volume in one second
(FEV1) of 2.10 I (predicted 3.2 1)

forced vital capacity (FVC) of 2.30 I (predicted
4).

Carbon monoxide transfer factor (TLCO) was
reduced to 70% predicted.

There was 5% improvement following
salbutamol nebulisers.

Whot is the likely diagnosis?

1- COPD

2- Asthma

3- Pulmonary embolus

4- Pulmonary fibrosis

5- Pneumothorax

Answer & Comments

Answer: 4- Pulmonary fibrosis

Although there is slight improvement with
salbutamol, the best answer is interstitial lung
disease/ pulmonary fibrosis.

The FEV1 / FVC ratio is 90% which suggests
restrictive lung disease rather than obstructive
lung disease. There is also reduced transfer
factor (TLCO) because pulmonary fibrosis
thickens the alveolar walls. Both of these
features are consistent with pulmonary
fibrosis.

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[Q: 1990] MRCPass - 2010
September

A patient who recently had a traumatic car
accident had to undergo splenectomy during
emergency surgery.

Which of the following is likely to be found in
the blood film of the patient?

1- Schistocytes

2- Poikilocytes

3- Howell Jolly bodies

4- Heinz bodies

5- Blast cells

that he had a HBAlc of 9. On examination, he
has a BMI of 34. Urine dipstick showed
Glucose ++ and Ketones +.

What is the likely diagnosis?

1- DM typel

2- DM type 2

3- MODY

4- Pancreatic failure

5- Drug induced diabetes

Answer & Comments

Answer: 2- DM type 2

Answer & Comments

Answer: 3- Howell Jolly bodies

This patient is unlikely to have Type 1 diabetes
and Maturity Onset Diabetes of the Young as
the age is > 25 years.

Howell Jolly bodies are nuclear remnants
which appear as basophilic (purple) spots on
the eosinophilic (pink) erythrocyte on a
standard H&E stained blood smear.

These inclusions are normally pitted out by
the spleen during erythrocyte circulation, but
will persist in individuals with functional
hyposplenia or asplenia.

Howell Jolly Body

The obese characteristic suggests type 1
diabetes and ketonuria which is mild can
occur in type 2 diabetes.

A 65 year old lady has epigastric pain for
several months and is referred for endoscopy.

A biopsy taken during the endoscopy confirms
MALT lymphoma.

Which one of the following associations for
Helicobacter pylori infection and gastric
lymphoma?

1- Gastro oesophageal reflux disease

2- Non ulcer forming gastritis

3- Duodenal ulcer

4- Pancreatic fistula

[Q: 1992] MRCPass-2010
September

[Q: 1991] MRCPass-2010
September

A 40 year old man has recently been
diagnosed with diabetes. He has been put on
oral hypoglycaemic drugs.

History revealed that he has three cousins
who also have diabetes. Blood tests revealed

5- Pernicious anaemia

Answer & Comments

Answer: 2- Non ulcer forming gastritis

Malignancies that occur in mucosa-associated
lymphoid tissue (MALT) are called MALT
lymphomas (MALTomas).

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Most of the MALTomas occur in the stomach,
and roughly 70% of gastric MALTomas are
associated with Helicobacter pylori infection.

H. pylori gastritis is common in individuals
who develop gastric lymphomas. Although the
aetiology is unknow n, this association is
established.

[Q: 1993] MRCPass - 2010
September

A couple presents to the genetic clinic for
counselling. The male partner has haemophilia
whilst the female partner has been screened
and is not a carrier.

Whot is the chance that a son would have
haemophilia?

1- 25%

2- 50%

3- 75%

4- All sons

5- None

Answer & Comments

Answer: 5- None

Haemophilia is X linked recessive.

In this case, if the affected X chromosome is
designated Xa, the father is XaY and mother
XX. The children would be carrying either XaX
or XY. In this situation all female children will
be carriers and all male children will not be
affected.

[Q: 1994] MRCPass-2010
September

A 65 year old woman presented with a four-
year history of increasing stiffness and
immobility which have led to multiple falls.
She had had some difficulty in fine finger
movement. Her Blood pressure was 130/90
mmHg lying and 135/95 mmHg standing.
Examination showed a mask like facies,

bradykinesia, nuchal and limb rigidity. She had
an asymmetrical tremor in her hands and
cogw heel rigidity in the arms. She had
diminished upward conjugate deviation of
eyes. There was also short-term memory loss.

What is the diagnosis?

1- Lewy body dementia

2- Alzheimer's disease

3- Parkinson's disease

4- Multi system atrophy

5- Progressive supranuclear palsy

Answer & Comments

Answer: 5- Progressive supranuclear palsy

A patient with parkinsonism and gaze palsy
suggests a diagnosis of progressive
supranuclear palsy.

Progressive supranuclear palsy (PSP), is also
known as Steele-Richardson-Olszew ski
syndrome. Characteristics include
supranuclear, primarily vertical, gaze
dysfunction accompanied by extrapyramidal
symptoms and cognitive dysfunction. The
disease usually develops after the sixth
decade of life. The most common symptoms
at disease onset are postural instability and
falls (60%); dysarthria (35%); bradykinesia
(15%); and visual disturbances such as
diplopia, blurred vision, burning eyes, and
light sensitivity

[Q: 1995] MRCPass-2010
September

A patient with atrial fibrillation was prescribed
digoxin.

What does it bind to in order to generate its
mode of action?

1- Calcium channel

2- Potassium channel

3- Beta receptors

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4- Na / K- ATPase

4- Pneumocystis carinii pneumonia

5- Aldosterone receptors

5- Schistosomiasis

Answer & Comments

Answer 4- Na / K- ATPase

Digoxin, also known as digitalis, is a purified
cardiac glycoside.

Digoxin binds to a site on the extracellular
aspect of the ?-subunit of the Na+/K+ ATPase
pump in the myocytes.

[Q: 1996] MRCPass - 2010
September

A 36-year-old woman presented to the
emergency department with fevers, cough,
and dyspnoea for one week.

She drinks 4 units of alcohol per day and
admitted to regular intravenous drug abuse.
On physical examination, the patient had a
temperature of 38°C, was tachypnoeic and
tachycardic. Blood pressure was 120/90
mmHg.

Examination of lungs revealed bilateral coarse
crackles and rhonchi. She had a soft systolic
murmur heard throughout the precordium.
The chest X ray is shown below :

What is the most likely diagnosis?

1- Calcification of the lung

2- Tuberculosis

3- Tricuspid endocarditis

Answer & Comments

Answer: 3- Tricuspid endocarditis

The best answers are either tuberculosis or
endocarditis.

In this case, due to a history of intravenous
drug use the most likely scenario is tricuspid
valve endocarditis leading to multiple lung
abscesses (as shown on the CXR). If multiple
cavities are present, the infection is likely due
to haematogenous dissemination (septic
emboli), and a source for this dissemination
should be sought. The source could be right¬
sided endocarditis (usually staphylococcal) or
infected venous thrombi. Tubercular cavities
are usually located in the upper zone, either
the posterior segment of the upper lobe or
apical segment of lower lobe.

[ Q: 1997 ] MRCPass - 2010
September

A 42 year old man had a cough and his GP
organized a chest X ray. This showed a
pneumothorax and he was referred to the
hospital. He does not have any symptoms of
breathlessness or chest pains. His BP was
110/80 mmHg, 02 sats were 99% on air &
pulse was 80/min. CXR shows that there is a
pneumothorax on the left with calculated size
involving 20% of the lung volume.

Which is the most appropriate step?

1- Observation as outpatient

2- Observation as inpatient

3- Needle aspiration as outpatient

4- Needle aspiration as inpatient

5- Discharge with outpatient follow up

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Answer & Comments

Answer: 5- Discharge with outpatient follow
up

An air rim of 2 cm or more means that the
pneumothorax occupies about 50% of the
pleural cavity and so this patient is likely to
have a rim of air < 2 cm.

The 2010 guideline can be downloaded here:
http://www.brit-thoracic.org.uk/Clinical-
Information/Pneumothorax/Pneumothorax-
Guideline.aspx

A 33 year old man has had a 6 month history
of bilateral hip pains and back pains. There is
not past medical history of trauma to the
back. Non steroidal anti-inflammatory drugs
helped to relieve his symptoms.

What is the likely diagnosis?

1- Gluteus medius syndrome

2- Osteoarthritis

3- Avascular necrosis of the hip

4- Sacroilitis

5- Lumbar canal stenosis

[Q: 1998] MRCPass - 2010
September

Answer & Comments

Answer: 4- Sacroilitis

Pain and stiffness in the lower back or
buttocks, especially in the morning is typical of
sacroilitis.

It is typically helped by NSAIDS or steroids. X
rays will help to confirm the diagnosis. It is

associated with various inflammatory diseases
e.g. ankylosing spondylitis, psoriatic arthritis.

Gluteus medius syndrome can cause buttock
pains but there should be a history of overuse
of the gluteus muscles which make it
consistent with the diagnosis.

A 45 year old man presented with a history of
wheeze, cough and fevers for over 3 months.
On physical examination, chest auscultation
revealed decreased air entry on right upper
lung field. Chest X ray pulmonary infiltrates.
Investigations show that the sputum culture
was negative for acid fast bacilli.

What is the best test to diagnose allergic
bronchopulmonary aspergillosis?

1- Lung function test

2- Bronchoscopy

3- Precipitin antibodies

4- Eosinophil count

5- CT scan of the chest

[Q: 1999] MRCPass-2010
September

Answer & Comments

Answer: 3- Precipitin antibodies

ABPA is a hypersensitivity reaction to A
fumigatus colonization of the
tracheobronchial tree which eventually leads
to bronchiectasis.

Eosinophil counts an IgE levels are typically
high. Lung function tests show decreased lung
volumes and gas transfer. Skin prick testing to
allergens from Aspergillus fumigatus are
positive. Precipitin antibodies (IgG) are
commonly found in the serum. Both of these
tests are convenient to confirm a diagnosis of
ABPA.

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^ [ Q: 2000 ] MRCPass- 2010

| | September

A 46-year-old man presents with back pain
and on lateral spine x rays was found to have
vertebral collapse. His past history is
unremarkable. He does not smoke and there
is no significant alcohol history. A bone scan
was organised which confirmed that he had
osteoporosis.

What test should be sent off to identify the
couse of osteoporosis?

1- Thyroid function

2- Troponin

3- Prolactin

4- Testosterone

5- Blood glucose

Which one of following best investigation
diagnose cause of renal failure?

1- Urine for casts

2- IV urogram

3- Renal angiography

4- Renal biopsy

5- CT of the kidneys

Answer & Comments

Answer: 3- Renal angiography

The history of hypertension, progressive renal
impairment and small kidney size suggest
renovascular disease.

The best investigation in this case would be
either renal angiography or MR angiography.

Answer & Comments

[ Q: 2002 ] MRCPass - 2010

Answer: 4- Testosterone

h_]

September

Osteoporosis in a young male is unusual, as it
is usually seen in post menopausal women.

It is known that testosterone deficiency in a
young male and also androgen antagonists in
older males with e.g. prostate cancer can
cause osteoporosis. Any features of
hypogonadism or hypercalcemia should be
elicited. Hyperprolacinemia would causes
hypogonadism so a testosterone level would
be far more relevant. Hyperthyroidism would
be present for a considerable length of time
before producing osteoporosis.

A 32 year old woman presents with blurred
vision and headaches. She has described
having had a severe headache at the back of
the head and neck 3 weeks ago but did not
seek help then. She has a history of
hypertension. On examination, she had
swollen discs with blurred disc margins
bilaterally, and had bilateral 6th nerve palsy.

What is the likely diagnosis?

1- Multiple sclerosis

2- Vertebral artery dissection

3- Subarachnoid haemorrhage

[Q: 2001] MRCPass-2010
September

A 65-year-old is referred for investigation of a
progressive history of worsening kidney
disease. He has a long history of hypertension.
Dipstick analysis of urine shows Blood + and
protein +. The Urea is 20 mmol/l and
Creatinine 260 umol/l 100). An ultrasound of
abdomen requested shows left sided kidney
size of 7.5 cm and right kidney size of 10.2 cm.

4- Benign intracranial hypertension

5- Essential hypertension

Answer & Comments

Answer: 3- Subarachnoid haemorrhage

Subarachnoid hemorrhage should alw ays be
suspected in patients with a typical
presentation which includes a sudden onset of
severe headache (frequently described as the

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"w orst ever"), with nausea, vomiting, neck
pain, photophobia, and loss of consciousness.

Physical examination may reveal retinal
hemorrhages, meningism, a diminished level
of consciousness, and localizing neurologic
signs. Localising signs usually includes third-
nerve palsy (posterior communicating
aneurysm), sixth-nerve palsy (increased
intracranial pressure), bilateral low
erextremity weakness or abulia (anterior
communicating aneurysm), and the
combination of hemiparesis and aphasia or
visuospatial neglect (middle cerebral-artery
aneurysm).

In benign intracranial hypertension, patients
usually present with symptoms related to
increased intracranial pressure. These
symptoms include headache, transient visual
obscurations, and diplopia due to unilateral or
bilateral sixth nerve palsy. However, in this
case the acute nature of the headache does
not make BIH likely.

A 58 year old man presents with dizziness and
palpitations. The ECG shows a a broad
complex tachycardia.

Which of the following features favours
ventricular tachycardia over supraventricular
tachycardia with bundle branch block?

1- Left bundle branch block

2- Atrioventricular dissociation

3- Heart rate of 180

4- QRS complex of 120ms

5- Saw tooth waves

[Q: 2003] MRCPass - 2010
September

Answer & Comments

Answer: 3- Heart rate of 180
Differentiating SVT from VT
Features that favour VT are :

QRS of > 140ms,

cannon a waves on JVP, fusion and/or capture
beats

dissociated p waves (p wave dissociation)

history of ischaemic heart disease,

right bundle branch block with left axis
deviation,

concordance of the QRS complexes in the
chest leads

HR >170 beats per minute.

A patient is being assessed for renal
transplantation.

Which one of the following HLA compatibility
is the most important?

1- HLA A

2- HLA B

3- HLAC

4- HLA DR

5- HLAG

[Q: 2004] MRCPass-2010
September

Answer & Comments

Answer: 4- HLA DR

ABO blood group matching is the most
important, and HLA matching is a relatively
minor predictor of transplant outcomes.

However, among HLA matches, DR matching
has a greater effect than that of B or A. A
study found that HLA-DR mismatches (and the
number of rejection episodes) correlated with
poor long-term survival

[Q: 2005] MRCPass-2010
September

A 52-year-old Asian man presented to the
hospital with chest pain and his ECG showed

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antero lateral ST elevation myocardial
infarction. He was thrombolysed with
tenecteplase and his chest pains settled, two
days later, he had worsening shortness of
breath at rest.

On physical exam patient was in respiratory
distress sitting up right, blood pressure was
150/90 mmHg, heart rate 100 bpm, regular,
respiratory rate 28/min. Neck veins were not
distended and he had no ankle edema. On
examination of the cardiovascular system he
had an apical systolic murmur. He had
bilateral coarse crepitation all over the lungs.

Whot is the likely cause of his deterioration?

1- Dressler's syndrome

2- Pericardial effusion

3- Ventricular septal rupture

4- Papillary muscle rupture

5- Atrial Fibrillation

1- Carbamazepine

2- Chlorpropamide

3- Fluoxetine

4- Furosemide

5- Lithium

Answer & Comments

Answer: 5- Lithium

This patient is having drug induced
nephrogenic Diabetes Insipidus based upon
her polyuria, low urine osmolality, high plasma
osmolality and high sodium.

This is because of a lack of response of the
renal tubules to the hormone ADH, leading to
an inability to reabsorb water causing low
urine osmolality and high urine sodium. The
most likely causes of nephrogenic Diabetes
Insipidus are Lithium and Demeclocycline.

Answer & Comments

Answer: 4- Papillary muscle rupture

Papillary muscle rupture, as can be caused by
a myocardial infarction and or ischemia,
leading to the complication of mitral valve
prolapse.

The history here of myocardial infacrtion and
also a systolic murmur of mitral regurgitation
will fit this description.

[Q: 2006] MRCPass - 2010
September

A 50 year old lady complained of having to
pass urine frequently for several weeks. She
was on medications for bipolar disorder,
hypertension and diabetes. On investigation
the following results were found:

Serum sodium 149 mmol/l

Plasma osmolality 304 mosmol/l (275-290)
Urine osmolality 150 mosmol/l (350-1000)
What drug may have caused this?

[Q: 2007] MRCPass-2010
September

A 70 year old woman presents to A&E with
decreased consciousness and weakness. Her
neighbour has not seen her for several days
but found her on the floor. A letter provided
information that she had a history of
hypothyroidism and was normally on beta
blockers and thyroid replacement. On
examination, her temperature is 35°C and she
has a blood pressure of 85 / 40 mmHg. GCS is
11 / 15. A Blood sugar was measured at 2.3
mmol/l.

Blood results show :

sodium 127 mmol/l

potassium 3.6 mmol/l

urea 6 |imol/l

creatinine 100 |imol/l

What is the next best management step?

1- 10% Dextrose solution

2- Oral Thyroxine

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3- IV Hydrocortisone

4- IV T3

5- Sliding scale insulin

Answer & Comments

Answer: 3- IV Hydrocortisone

The scenario is consistent with either
myxedema coma or Addison's disease.

In both situations, IV hydrocortisone is
recommended.

Myxedema crisis occurs most commonly in
elderly patients with long-standing
undiagnosed or undertreated hypothyroidism
who experience an additional significant
stress, including cold environment, infection,
or certain medications. However, to avoid
adrenal crisis, thyroxine replacement for
hypothyroidism should only be initiated after
concomitant glucocorticoid deficiency has
either been excluded or treated.

Rew arming with blankets or warm fluids are
important. Intravenous glucose and normal
saline should be carefully administered. IV
hydrocortisone (lOOmg) should be
administered. An intravenous loading dose of
200-500 meg of levothyroxine is also
recommended if myxedema is suspected,
followed by a daily intravenous dose of 50-100
meg.

[Q: 2008] MRCPass - 2010
September

A 56 year old man presents with a 5 day
history of left arm pain and weakness. On
examination, he has increased tone in the left
arm and weakness in the biceps and triceps
distribution. There were absent biceps and
supinator reflexes. The triceps reflex was
brisk. Sensation was reduced around the
lateral part of the forearm and elbow .
Proprioception was normal.

Whot is the likely diagnosis?

1- Syringomyelia

2- C5 and C6 disc herniation

3- Transverse myelitis

4- Neuralgic amyotrophy

5- Guillain barre syndrome

Answer & Comments

Answer: 2- C5 and C6 disc herniation

This clinical history fits C5 / 6 disc herniation
or cord compression.

The weakness and distribution of abnormal
reflexes - biceps jerk (C5, C6), triceps jerk (C6,
C7) and supinator jerk (C5, C6) suggest that
the areas around C5 and C6 being affected.
There are mixed upper motor neuron
(increased tone) and lower motor neuron
(absent reflex). The biceps and supinator
reflexes (C5 and C6) may be absent, with a
brisk triceps reflex (C7). This pattern is almost
pathognomonic of cord compression because
of cervical spondylosis at the C5-C6
interspace.

[Q: 2009] MRCPass-2010
September

A 60 year old man presents with dysphagia
and dysphonia. Cranial nerve examination
revealed left-sided partial ptosis with miosis,
left sided facial weakness, tongue deviation to
the left, an absent gag reflex, palatal palsy on
the left, a weak voice, and a wasted left
sternocleidomastoid muscle.

Which one of the following areas is
neurological damage most likely?

1- Pons

2- Lateral ventricles

3- Jugular foramen

4- Stylomastoid foramen

5- Cerebellopontine

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Answer & Comments

Answer: 3- Jugular foramen

The diagnosis is likely to be either Villaret's
syndrome or a jugular foramen syndrome.

Villaret's is a rare syndrome characterized by
an ipsilateral paralysis of cranial nerves
numbers IX ,X, XI, XII, and it can also involve
the cervical ganglia of the sympathetic trunk.
The jugular foramen allows passage through
of IX, X and XI cranial nerves.

A 36 year old man has developed
gynaecomastia after a new medication was
commenced for 6 months.

Which one of the following drugs is likely to
hove coused the gynoecomostio?

1- Amiodarone

2- Buserelin

3- Thioridazine

4- Erythromycin

5- Ibuprofen

[Q: 2010] MRCPass - 2010
September

Answer & Comments

Answer: 2- Buserelin

Common drugs which can cause
gynaecomastia are digoxin, oestrogens,
spironolactone, cimetidine, verapamil and
nifedipine.

Buserelin is a new one to add to the MRCP list.

Buserelin is a Gonadotropin-releasing
hormone agonist (GnRH agonist). Like other
GnRH agonists, buserelin may be used in the
treatment of hormone-responsive cancers
such as prostate cancer or breast cancer.
Occasional gynaecomastia (increase in breast
size) which is usually painless, atrophy of the
testes, decrease in libido and potency may
occur.

[Q: 2011] MRCPass-2010
September

A 24 year old health worker had a needlestick
injury on a finger after taking blood from a
patient who was positive for HIV. Following
the injury, the wound on the finger was
thoroughly cleaned under clean running
water.

Whot is the percentage chonce that the
worker might contract HIV?

1- 1 in 3

2- 1 in 30

3- 1 in 300

4- 1 in 3000

5- 1 in 30000

Answer & Comments

Answer: 3-1 in 300

The rate of occupational transmission from an
HIV-positive source is believed to be 0.3% for
a percutaneous exposure, which is much
lower than Hepatitis B or Hepatitis C
transmission.

Taking this number into account, the risk
works out to be 1 in 300.

[Q: 2012] MRCPass-2010
September

A 50- year- old male presented with sudden
worsening of breathlessness after a severe
episode of pneumonia was thought to have
developed acute respiratory distress
syndrome (ARDS).

Which of the following features would support
o diagnosis of ARDS?

1- High pulmonary capillary wedge pressure

2- High protein pulmonary oedema

3- Hypercapnea

4- Increased lung compliance

5- Normal chest x- ray

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Answer & Comments

Answer: 2- High protein pulmonary oedema

Answer: B): high protein pulmonary oedema

ARDS is characterised by hypoxaemia, reduced
lung compliance (stiff lungs) and pulmonary
infiltrates on the chest x- ray.

Standard teaching is that urate low ering
drugs should not be introduced during an
acute episode as it may worsen or prolong the
episode; furthermore initiation of
hypouricaemic treatment may precipitate
acute gout. Colchicine and NSAIDs can be used
in the acute situation.

There is also no cardiogenic cause for
pulmonary oedema (the Pulmonary Capillary
Wedge pressure has to be normal or less than
18mmHg to confirm this).

Histologically, in ARDS there is damage to the
capillary and endothelial cell linings, resulting
in leakage of proteins into the interstitial and
alveolar spaces at normal pulmonary capillary
hydrostatic pressures - hence causing
pulmonary oedema with high protein. In
cardiac failure the protein levels of pulmonary
oedema fluid are low .

A 50 year old man with a past history of
alcohol abuse presents with a painful red and
warm ankle which was tophaceous. Gout was
diagnosed and he was prescribed allopurinol.

What is allopurinol's mechanism of action?

1- Uricosuric drug

2- Non steroidal anti inflammatory drug

3- Microtubule inhibitor

[Q: 2013] MRCPass - 2010
September

[Q: 2014] MRCPass-2010
September

How does the body handle excess amounts of
cortisol?

1- Binds to albumin

2- Binds to adipose tissue

3- Inactivated in the liver

4- Excreted as free cortisol in the urine

5- Broken down by enzymes

Answer & Comments

Answer: 4- Excreted as free cortisol in the
urine

Most serum cortisol (all but about 4%) is
bound to proteins, including corticosteroid
binding globulin (CBG) and serum albumin.

However, when there is excess cortisol there
will be insufficient binding capacity. This
excess free cortisol is excreted in the urine,
which is why it is a good diagnostic test for
Cushing's syndrome.

4- Xanthine oxidase inhibitor

5- Dihydrofolate reducatase inhibitor

Answer & Comments

Answer: 4- Xanthine oxidase inhibitor

Hypouricaemic agents essentially comprise of
xanthine oxidase inhibitors (for example,
allopurinol) and uricosuric agents (for
example, probenecid, sulphinpyrazone,
benzbromarone or azapropazone).

[Q: 2015] MRCPass-2010
September

A 54 year old man presents with acute chest
pains 1 hour ago. On arrival to the emergency
department, he was found to have ST
elevation of 2-3 mm from leads VI to V4 and
deep T wave inversion in the inferior leads. He
was transferred immediately for coronary
angiography.

What is the likely finding?

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1- 70% stenosis of the left anterior descending
artery

2- 70% stenosis of the right coronary artery

3- Total occlusion of the left anterior
descending artery

4- Total occlusion of the right coronary artery

5- Total occlusion of the right coronary artery
and the left anterior descending artery

Answer & Comments

Answer: 3- Total occlusion of the left anterior
descending artery

The distribution of the ECG changes in the
chest leads Vl-6 suggests that it is an anterior
myocardial infarction and hence total
occlusion of the left anterior descending
artery will be a likely finding.

The T wave inversions in the inferior leads are
due to reciprocal changes.

[Q: 2016] MRCPass - 2010
September

A 75-year-old woman presented with a 18
month history of progressive dysphagia to
both solids and liquids, as well as a 3 kg weight
loss. She typically complained of heartburn
especially when lying down and after food. On
examination, there were no palpable masses
or lymphadenopathy found.A chest X ray
showed dilatation of the oesophagus with a
fluid level.

Achalasia is characterized by difficulty sw
allowing, regurgitation, and sometimes chest
pain.

the lower esophageal sphincter fails to relax,
leading to dilatation of the oesophagus. On a
barium sw allow , this leads to a bird's beak
appearance.

[Q: 2017] MRCPass-2010
September

A 63 year old man presents with an episode of
amnesia for the second time in two months. 2
days ago he had an episode of confusion,
according to his wife. He was, However, able
to have a normal conversation despite having
been found wandering. After 2 hours, he
abruptly returned to normal and could not
remember what happened.

What is the most likely diagnosis?

1- Alcoholic encephalopathy

2- Subarachnoid haemorrhage

3- Complex partial seizure

4- Transient ischaemic attack

5- Transient global amnesia

Answer & Comments

Answer: 5- Transient global amnesia

Transient global amnesia (TGA) is a temporary
and isolated disorder of memory which may
last several hours.

What is the most likely diagnosis?

1- Oesophageal carcinoma

2- Pancreatic malignancy

3- Achalasia

4- Gastroduodenal ulcer

5- Zollinger Ellison syndrome

Answer & Comments

Answer: 3- Achalasia

Precipitating factors include sexual
intercourse and heavy physical exercise,
particularly sw imming in cold water.

[Q: 2018] MRCPass-2010
September

A 53-year-old man with a history of anaemia
and abdominal discomfort is diagnosed as
having chronic myeloid leukaemia.

What is the mechanism of action of imatinib?

1- EGF receptor antagonist

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2- Anti VEGF receptor antagonist

3- Anti-CD20 monoclonal antibody

4- P53 inhibitor

5- Tyrosine kinase inhibitor

Answer & Comments

Answer: 5- Tyrosine kinase inhibitor

Imatinib (Gleevec) is an inhibitor of the
tyrosine kinase associated with the BCR-ABL
defect.

It is used in treating chronic myelogenous
leukemia (CML) and gastrointestinal stromal
tumors.

A 55 year old man has multiple endocrine
neoplasia type II. There is a history of
parathyroid neoplasia and

phaeochromocytoma.

Which one of the following thyroid conditions
is associated?

1- Anaplastic thyroid carcinoma

2- Follicular thyroid carcinoma

3- Papillary thyroid carcinoma

4- Medullary thyroid carcinoma

5- Insulinoma

[Q: 2019] MRCPass - 2010
September

Answer & Comments

Answer: 4- Medullary thyroid carcinoma

MEN 1 associations are: pituitary tumour,
parathyroid hyperplasia/tumour, pancreatic
tumours (most commonly gastrinoma /
insulinoma).

MEN 2a is associated with medullary thyroid
carcinoma (MTC), parathyroid tumours (10-
20%) and pheochromocytoma (20-50%).

MEN 2b is associated with presentation of
medullary thyroid carcinoma, parathyroid

tumours and pheochromocytoma +
ganglioneuromatosis (pathognomonic).

[Q: 2020] MRCPass-2010
September

A 75-year-old woman was admitted to the
hospital because of fever, chills, headaches
and myalgia.

Her husband mentions that she has vomiting
and is very confused. She also had new
symptoms of urinary incontinence. She has
recently returned from a seven-day holiday in
Kenya. On physical examination, her blood
pressure was 105/70 mmHg, pulse rate 120
beats/ minute and body temperature 39°C.
Her MMSE score is 17 / 30. Except for right
upper abdominal pain, there were no other
abnormalities, and no hepatosplenomegaly.
Neurological examination was normal.
Laboratory investigations showed raised liver
enzymes, mild renal dysfunction. Urine
dipstick showed 1+ proteinuria and nitrite -ve.

What is the most likely infection?

1- Urinary Tract Infection

2- Dengue Fever

3- Cerebral Malaria

4- Leptospirosis

5- Listeria

Answer & Comments

Answer: 3- Cerebral Malaria

P. falciparum infection is common in Kenya.
The acute history and associated confusion
and renal involvement makes malaria most
likely. P falciparum can cause cerebral malaria
(confusion, seizures, headaches), pulmonary

edema, rapidly developing anemia, and renal
problems. Proteinuria is an early sign of renal
involvement.

Dengue is likely to be associated with a rash
and thrombocytopenia. Urinary tract infection

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doesn't quite fit with the scenario or travel to
Kenya and should not cause headaches.

[Q: 2021] MRCPass - 2010
September

A 80 year old woman presents with a sw elling
over the right side of her nose. The lesion was
noticed 4 years ago and was little changed. On
examination it was smooth, shiny and non
pigmented.

Whot is the probable diagnosis?

1- Trophic ulcer

2- Basal cell carcinoma

3- Lupus vulgaris

4- Seborrhoeic warts

5- Squamous cell carcinoma

Answer & Comments

Answer: 2- Basal cell carcinoma

Basal cell carcinomas can have many different
appearances: a red patch or irritated area; a
smooth, shiny and waxy looking bump; a
white or yellow scar-like area; a smooth
reddish growth; or an open sore that won't
heal, bleeds or oozes.

They are slow growing as described in this
case, and rarely metastasise.

Basal Cell Carcinoma

[Q: 2022] MRCPass - 2010
September

A 30 year old lady with pulmonary
hypertension is prescribed bosentan.

What is its mechanism of action?

1- Phosphodiesterase 5 inhibitor

2- Calcium channel antagonist

3- Prostaglandin analogue

4- Vasopressin analogue

5- Endothelin receptor antagonist

Answer & Comments

Answer: 5- Endothelin receptor antagonist

Bosentan is a competitive antagonist of
endothelin-1 at the endothelin-A (ET-A) and
endothelin-B (ET-B) receptors.

Under normal conditions, endothelin-1
binding of ET-A or ET-B receptors causes
pulmonary vasoconstriction.

By blocking this interaction, bosentan
decreases pulmonary vascular resistance.

[Q: 2023] MRCPass-2010
September

A 36 year old lady with systemic lupus
erythematosus has features of joint arthritis
and photosensitive skin rashes. She is being
followed up in the rheumatology clinic. During
assessment , which one of these tests is the
most useful for monitoring disease activity?

1- Antinuclear antibody

2- C3 and C4

3- Anti Sm antibody

4- ESR

5- Anti CCP antibody

Answer & Comments

Answer: 2- C3 and C4

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Many factors may be used to monitor disease
activity (according to the Systemic Lupus
Erythematosus Disease Activity Index - see link
below).

Falling levels of C3 and C4 may herald a lupus
flare in patients. Antinuclear antibodies (ANA)
are positive in more than 95% of patients with
lupus and therefore not useful for monitoring
disease activity. Antibodies to dsDNA may
fluctuate with disease activity and rising
antibodies to dsDNA and can help in
monitoring disease activity. Other routinely
available autoantibodies have not been
demonstrated to be helpful as markers of
lupus activity.

http://www.rheumatology.org/practice/clinic

al/indexes/sledai.asp

[Q: 2024] MRCPass-2010
September

Which one of the following techniques is used
to determine the molecular structure of
protein?

1- Northern blotting

the given sample of tissue homogenate or
extract (e.g. in HIV testing, or to detect prions
in Bovine Spongiform Encephalopathy).

Northern blotting detects RNA and Southern
blotting detects DNA.

[Q: 2025] MRCPass-2010
September

A 26 year old man was brought into hospital
having drunk 2 bottles of engine coolant. He
was found to have metabolic acidosis and was
treated with fomepizole.

What is its mechanism of action on alcohol
dehydrogenase?

1- Competitive inhibitor

2- Non competitive inhibitor

3- Specific Agonist

4- Anti-metabolite

5- Neutralisation

Answer & Comments

Answer: 1- Competitive inhibitor

2- Southern blotting

3- X ray crystallography

4- Western blotting

5- Polymerase chain reaction

Answer & Comments

Answer: 1- Northern blotting

Fomepizole or 4-methylpyrazole is indicated
for use as an antidote in confirmed or
suspected methanol or ethylene glycol
poisoning.

It is a competitive inhibitor of alcohol
dehydrogenase, the enzyme that catalyzes the
initial steps in the metabolism of ethylene
glycol and methanol to their toxic metabolites.

X-ray crystallography is a method of
determining the arrangement of atoms within
a crystal, in which a beam of X-rays strikes a
crystal and diffracts into many specific
directions.

The method reveals the structure of many
biological molecules, including vitamins,
drugs, proteins and nucleic acids such as DNA.

The Western blot is a technique involving
electrophoresis to detect specific proteins in

[Q: 2026] MRCPass-2010
September

A 65-year-old female is brought to A&E by her
family, who are concerned about her
increasing confusion over the past 2 days.
There is a history of diarrhea in the preceding
few days. On examination she is found to be
pyrexial at 38oC. Breath sounds are clear and
there is mild tenderness in the lower

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abdomen. There was no focal neurological
signs.

Blood tests reveal :

Hb 9.6 g/dl
WCC 12 x 10 9 /l
Platelets 65 x 10 9 /l
sodium 138 mmol/l
potassium 4.7 mmol/l
Urea 18.1 mmol/l
Creatinine 210 mmol/l

A blood film shows schistocytes and
thrombocytopenia.

What is the most likely diagnosis?

1- Wegener's granulomatosis

2- Thrombotic thrombocytopenic purpura

3- Goodpasture?fs disease

erythematous, swollen leg. An ultrasound scan
confirmed the diagnosis of deep vein
thrombosis. Upon questioning he has a family
history of thrombophilia.

Which one of the following is likely to couse
resistance to activation by protein C?

1- Anti thrombin III deficiency

2- Protein C deficiency

3- Protein S deficiency

4- Factor V leiden variant

5- Antiphospholipid syndrome

Answer & Comments

Answer: 4- Factor V leiden variant

Factor V Leiden variant is the most common
hereditary hypercoagulability disorder
amongst Europeans.

4- Idiopathic thrombocytopenic purpura

5- Rapidly progressive glomerulonephritis

Answer & Comments

Answer: 2- Thrombotic thrombocytopenic
purpura

Thrombotic thrombocytopenic purpura (TTP),
involvement of the CNS predominates in TTP
(neurological signs) whilst in HUS there is
mainly renal involvement.

Most cases of TTP arise from inhibition of the
enzyme ADAMTS13, a metalloprotease
responsible for cleaving large multimers of
von Willebrand factor (vWF) into smaller
units.

Neurologic symptoms (confusion, headaches,
stroke), low platelet count, renal impairment
and microangiopathic haemolytic anaemia are
present.

A 30 year old man presented with an

[Q: 2027] MRCPass-2010
September

Leiden variant of factor V cannot be
inactivated by activated protein C.

To diagnose Factor V leiden deficiency, Most
laboratories screen 'at risk' patients with
either a snake venom (e.g. dilute Russell's
viper venom time) based test or an aPTT
based test. This is done by running two tests
simultaneously, one test is run in the presence
of activated protein C (APC) and the other, in
the absence. A ratio is determined based on
the two tests and the results signify to the
laboratory whether APC is working or not.

A 55 year old patient has undergone gastric
bypass surgery for treatment of obesity 6
months ago. She is not compliant with
prescribed vitamins and now presents with
general lethargy.

Which of the following is commonly deficient
in Gastric bypass surgery?

1- Iron

2- Folate

[Q: 2028] MRCPass-2010
September

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3- Zinc

4- Vitamin K

5- Vitamin C

Answer & Comments

Answer: 1- Iron

Gastric acidity helps absorption of iron and
also intrinsic factor produced in the stomach
helps absorption of B12.

Following gastric bypass surgery, iron and B12
deficiency are common (about 30% of
patients).

As B12 isn't on the answer options Iron is the
best answer here. Folate deficiency following
obesity surgery is rare.

A 27 year old man presents with a 6 month
history of low back pain. The pain radiates to
his buttocks. There is associated stiffness
which is worse in the morning and after
periods of inactivity.

Which of the following signs is most likely to
be present?

1- Positive straight leg test

2- Positive femoral stretch test

3- Positive Trendelenburg test

4- Sacroiliac joint tenderness

5- Global immobile vertebrae

[Q: 2029] MRCPass - 2010
September

hip and shoulder joints, and a search for signs
of enthesitis are critical in making an early
diagnosis of AS. Important physical findings
include tenderness over sacroiliac joints,
vertebral spinal processes, iliac crest, anterior
chest wall, calcaneus ischial tuberosities,
greater trochanters, and tibial tubercles.

With longer disease duration and disease
progression, the spine becomes increasingly
stiff, leading to loss of spinal mobility in all
planes and restricted chest expansion.

[Q: 2030] MRCPass-2010
September

A 52 year old man with heavy alcohol intake
presents with haemetemesis. On examination,
he had signs of pallor, jaundice and ascites. He
was transfused 4 units of blood and when his
blood tests were available, he had significant
liver and renal impairment which confirmed
hepatorenal syndrome. Terlipressin was
commenced.

What is the mechanism of action of
terlipressin ?

1- Increase eprythropoietin levels

2- Vasodilation of coronary arteries

3- Decrease hypoxia

4- Splanchnic vasoconstriction

5- Decrease renal perfusion

Answer & Comments

Answer: 4- Splanchnic vasoconstriction

Answer & Comments

Answer: 4- Sacroiliac joint tenderness

The diagnosis is ankylosing spondylitis and the
sign is related to early disease so the best
answer is sacroiliac joint tenderness.

Examination of the sacroiliac joints and the
spine (including the neck), measurement of
chest expansion and range of motion of the

Terlipressin (triglycyl lysine vasopressin) is a
synthetic analogue of vasopressin, which has
been used in the treatment of acute variceal
hemorrhage and in hepatorenal syndrome.

In hepatorenal syndrome, it helps by reversing
the extreme splanchnic arterial vasodilation
that occurs in these patients, effectively
increasing arterial blood volume.

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[Q: 2031] MRCPass - 2010
September

A 51-year-old female was seen in the
Emergency department with a 2 day history of
headaches and fever. On examination, there
was also evidence of meningism as shown by
presence of a positive Kernig's sign. The
patient had a temperature of 38.5°C. A lumbar
puncture was performed. CSF showed
evidence of gram positive bacilli.

Whot is the diagnosis?

1- Hemophilus influenzae

2- Stapylococcus aureus

3- Listeria monocytogenes

4- Streptococcus pneumoniae

5- Legionella pneumophila

Answer & Comments

Answer: 3- Listeria monocytogenes

This patient has signs consistent with
meningitis.

Gram positive bacilli (rods) include Clostridia
(clostridium tetani), listeria monocytogenes
and bacilli (bacillus cereus). Legionella and
haemophilus are gram negative bacilli.

[Q: 2032] MRCPass - 2010
September

A 55-year-old man with a history of Crohn's
disease comes for review. 5 years ago he had
abdominal surgery and has been symptom
free until now. Recently though, he has
started to experience discomfort around the
stoma site from the pervious surgery. On
examination a deep erythematous, violaceous
ulcer is noted with a ragged edge. The
surrounding skin is erythematous and swollen.

Whot is the most likely diagnosis?

1- Erythema nodosum

4- Necrotising fasciitis

5- Crohn's disease ulceration

Answer & Comments

Answer: 3- Pyoderma gangrenosum

Pyoderma gangrenosum is associated with
inflammatory bow el disease and may be seen
around the stoma site.

Treatment is usually with

immunosuppressants.

Pyoderma Gangrenosum

[Q: 2033] MRCPass-2010
September

A 55-year-old man presented because of a
fever (up to 40°C) that had begun 12 days
earlier and persisted despite treatment with
oral antibiotics and anti-inflammatory drugs.

The fever episodes occurred every 48 hours,
with high peaks followed by abrupt resolution.
He had just returned from India a month ago,
and had not received any anti-malarial
prophylaxis a.

On presentation, he was pyrexial and pale,
tachycardic and had hepatosplenomegaly.
Microscopy of peripheral blood smears
showed trophozoites with a parasitemia of
1.5%. Some enlarged, infected erythrocytes,
with morphology typical of Plasmodium vivax
parasites, were observed.

Whot is the best ontimoloriol treatment?

2- Contact dermatitis

1- Quinine

3- Pyoderma gangrenosum

2- Chloroquine

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3- Mefloquine

4- Pyrimethamine and sulphadiazine

5- Artesunate

Answer & Comments

Answer: 2- Chloroquine

Plasmodium vivax is found mainly in Asia,
Latin America, and in some parts of Africa.

Chloroquine is the treatment of choice for
vivax malaria, except in Indonesia's Irian Jaya
region and Papua New Guines, where
chloroquine resistance is common (then
artesunate is the treatment of choice).
Mefloquine is an alternative.

A 34 year old African man with known HIV
infection presents with several episodes of
seizures. His CD4 count was 130 cells/mm 3
when measured 1 month ago. On
examination, he had a temperature of 38 °C
and was confused with an MTS score of 5/10.
There were no focal neurological signs. He had
an MRI scan which shows multiple ring
enhancing lesions. CSF examination showed
an elevated protein count, lymphocytosis and
normal

glucose levels. The CSF cryptococcal antigen
was negative. A chest X ray was normal.

Whot is the likely diagnosis?

1- Progressive multifocal

leukoencephalopathy

2- Cerebral toxoplasmosis

3- Cerebral lymphoma

4- Tuberculosis

5- Bacterial meningitis

[Q: 2034] MRCPass-2010
September

The likely diagnosis is cerebral toxoplasmosis
as there are multiple ring enhancing lesions.

Lymphoma usually causes single enhancing
lesions and PML is less frequently ring
enhancing. Tuberculosis frequently causes
significantly low glucose levels.

Cerebral Toxoplasmosis

[Q: 2035] MRCPass-2010
September

A 23-year-old woman comes for review . She
was diagnosed with asthma two years ago and
is currently using a salbutamol inhaler lOOmcg
PRN combined with beclometasone
dipropionate inhaler 200mcg twice a day. She
continues to get frequent episodes of
wheeziness and shortness of breath with low
peak flow readings. She counted that she had
4 exacerbations in the last month. She has a
good inhaler technique and today her PEFR is
90% of predicted.

Whot is the most appropriate next step in
management?

1- Switch steroid to fluticasone propionate

2- Increase beclometasone dipropionate to
lOOOmcg bd

3- Trial of monteleukast

Answer & Comments

Answer: 2- Cerebral toxoplasmosis

4- Add salmeterol

5- Add tiotropium

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Answer & Comments

Answer: 4- Add salmeterol

The management of stable asthma is now well
established with a step-w ise approach:

Step 1:- Inhaled short-acting B2 agonist as
required

Step 2:- Add inhaled steroid at 200-800
mcg/day*

Step 3:- Add inhaled long-acting B2 agonist
(LABA), such as salmeterol

If control still inadequate, institute trial of
other therapies, leukotriene receptor
antagonist or slow release theophylline

[Q: 2036] MRCPass - 2010
September

A 63-year-old man is admitted with
palpitations to the Emergency Department.

contraindicated in broad complex
tachycardias. Adenosine can be given even
though it blocks the AV node as it is very short
acting.

[Q: 2037] MRCPass - 2010
September

A 61 year old man presented with fevers,
lethargy and 2 month history of malaise. He
also mentioned altered bow el habit. On
examination, he had a temperature of 39 C
and a soft systolic murmur in the mitral area.
He also had several splinter haemorrhages.
Blood culture results within 24 hours grew
streptococcus bovis.

What investigation will help determine the
underlying source of infection?

1- Abdominal x ray

2- Colonoscopy

3- CT scan of the chest

An ECG on admission shows a broad complex
tachycardia at a rate of 150 bpm. His blood
pressure is 124/82 mmHg and there is no
evidence of heart failure.

Which one of the following is least appropriate
to give?

4- Skin biopsy

5- Transoesophageal echocardiogram

Answer & Comments

Answer: 2- Colonoscopy

1- Procainamide

2- Lidocaine

3- Verapamil

4- Synchronised DC shock

5- Adenosine

A correlation exists between colon cancer and
Strep, bovis proliferation in the large intestine,
hence predisposing to endocarditis. The
patient needs a colonoscopy which may
identify a colorectal malignancy predisposing
to strep bovis bacteraemia and endocarditis.

Answer & Comments

Answer: 3- Verapamil

Verapamil should not be given to a patient
with a broad complex tachycardia as it may
precipitate ventricular fibrillation in patients
with ventricular tachycardia.

This is because calcium channels are
concentrated in the sino atrial and
atrioventricular nodes. Similarly, digoxin is

[Q: 2038] MRCPass-2010

September

A 66 year old woman complains of fevers,
weight loss, joint pains and diarrhoea. A
jejunal biopsy reveals flattened mucosa
containing periodic acid-Schiff (PAS) positive
macrophages.

What is the most likely diagnosis?

1- Coeliac disease

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2- Campylobacter infection

3- Tropical sprue

4- Whipple's disease

5- Giardiasis

Answer & Comments

Answer: 4- Whipple's disease

Whipple's disease, may be confirmed by small
bow el biopsy.

The T score is usually used to make treatment
decisions using standard deviation (SD).

The SD measures the difference between the
BMD and that of a healthy young adult (the
reference value). Every -1 SD ("minus 1
standard deviation") equals a 10 to 12%
decrease in bone density. T score results are
classified as follows:

A T score between 0 and -1 standard deviation
(SD) is considered to be normal.

This will show large, foamy PAS positive
macrophages in the lamina propria. Whipple's
disease affects mainly men aged 30 to 60. It is
caused by an infection with Trophyrema
whippelii. Symptoms of Whipple's disease
include diarrhea, inflamed and painful joints,
fever, and skin darkening. Severe
malabsorption results in weight loss along
with fatigue and weakness caused by anemia.

Antibiotics such as tetracycline, co-
trimoxazole and penicillin can be used for
treatment (6-12 months).

A 60 year old lady presented with a fall and
fractured writst. She was organised to have a
DEXA scan. This showed a T score of -2.6 in
the hip and a score of -2.1 in the femur.

What does this mean?

1- Normal values on the scan

2- Osteopenia of the hip and osteoporosis of
the femur

3- Osteoporosis of the hip and osteopenia of
the femur

4- Osteopenia of both areas

5- Osteoporosis of both areas

[Q: 2039] MRCPass - 2010
September

Answer & Comments

Answer: 3- Osteoporosis of the hip and
osteopenia of the femur

A T score between -1 and -2.5 SD is classified
as osteopenia (low bone mass).

A T score of -2.5 SD or less is classified as
osteoporosis (very low bone mass).

A 30-year-old female was referred for
evaluation of lethargy. 2 months prior to
referral, she had developed high grade
continuous fever of acute onset for which she
consulted a general practitioner. She was
administered various courses of antibiotics
and antiviral drugs, treatment but with no
relief. Physical examination revealed pallor
but no other physical signs. There was no
clubbing, cyanosis or any significant
lymphadenopathy.

Her blood tests results are: Hb 6.5 g/dl, MCV
79 fl, WCC 2.4 x 10 9 /l, platelets 85 x 10 9 /l.

What is the likely couse?

1- Acyclovir

2- Chloramphenicol

3- Trimethoprim

4- Amoxicillin

5- Erythromycin

[Q: 2040] MRCPass-2010
September

Answer & Comments

Answer: 2- Chloramphenicol

From the investigations, this patient is likely to
have aplastic anaemia.

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Aplastic anemia is sometimes associated with
exposure to substances such as benzene,
radiation, or to the use of drugs, including
chloramphenicol, sulphonamides,

carbamazepine, phenytoin, quinine, and
phenylbutazone (Some candidates answ ered
trimethoprim, but it is the incorrect choice as
it is the sulphonamide component that causes
aplastic anaemia rather than trimethoprim in
examples such as co-trimoxazole)

^ [ Q: 2041 ] MRCPass - 2010

0 September

Which one of the following is the most
common underlying mechanism leading to
long QTsyndrome?

1- Opening of calcium channels

2- Opening of potassium channels

3- Opening of sodium channels

4- Blocking sodium channels

5- Blocking potassium channels

Answer & Comments

Answer: 5- Blocking potassium channels

Most candidates answ ered either blockage of
sodium or potassium channels.

Although it can be caused by blockage of
sodium, potassium or calcium channels,
around 90% of inherited long QT syndrome
are due to defects in potassium channels

^ [ Q: 2042 ] MRCPass - 2010

I September

A 41 year old man presented to his GP
because of painful blisters on the backs of his
hands in the summer. He also had a similar
rash on the forehead. His face and forehead
were covered with thickly wrinkled,
hyperpigmented skin. The patient's urine was
reddish orange.

What is the likely diagnosis?

1- Contact dermatitis

2- Pityriasis rosea

3- Epidermolysis bullosa

4- Pemphigoid

5- porphyria cutanea tarda

Answer & Comments

Answer: 5- porphyria cutanea tarda

In porphyria cutanea tarda, the urine
fluoresces pink to red.

Porphyria cutanea tarda's onset is typically
during the fourth or fifth decade of life. The
disease tends to develop, recur, or worsen
during the spring and summer, when exposure
to sunlight is greatest (ie photosensitivity).
Though blisters are the most common skin
manifestations of PCT, other skin
manifestations like hyperpigmentation and
hypertrichosis (mainly on top of the cheeks)
also occur.

The most common photocutaneous
manifestations of porphyria cutanea tarda are
due to increased mechanical fragility after
sunlight exposure; erosions and blisters form
painful indolent sores that heal with milia
(cysts), dyspigmentation, and scarring. The
deficient enzyme in porphyria cutanea tarda is
uroporphyrinogen decarboxylase.

Porphyria Cutanea Tarda

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[Q: 2043] MRCPass - 2010
September

A 47 year old male presented to hospital with
a five day history of jaundice, fever, poor
appetite and rigors. He has recently been
treated for an infection and had been on a
course of antibiotics.

On examination, he was jaundiced. His blood
pressure was 130/70, pulse rate was 80 beats
per minute, heart sounds were normal. There
was no evidence of organomegaly or
tenderness on abdominal examination.

Bloods showed:

albumin 30 g/L

alkaline phosphatase 1866 U/L
gamma glutamyl transferase of 336 U/L
alanine transaminase 138 U/L
bilirubin 80 umol/L.

Which drug was likely to have been given?

1- Cefotaxime

2- Paracetamol

3- Amoxicillin

4- Flucloxacillin

5- Tramadol

Answer & Comments

Answer: 4- Flucloxacillin

Augmentin (Co-amoxiclav), flucloxacillin
cefotaxime and tetracyclines can cause
cholestatic jaundice.

Amoxicillin on its own can also cause
cholestatic jaundice but less commonly so
than flucloxacillin.

[Q: 2044] MRCPass - 2010
September

A 35 year old woman has pleuritic chest pains.
If she had pericarditis , on her ECG, the ST-
segment is:

1- Concave upwards

2- Convex upwards

3- Concave downwards

4- Convex downwards

5- Straight

Answer & Comments

Answer: 1- Concave upwards

The shape of the ST elevation is typically
described as concave upwards in acute
pericarditis.

In myocardial infarction, the ST elevation is
described as convex upwards.

http://www.aafp.org/afp/980215ap/marinell.

html

A 75 year old woman was referred with a two-
month history of generalised weakness, fever,
and weight loss.

There was no other relevant past medical
history. There was no palpable splenomegaly.
The Hb was 9.5 g/dl,

white cell count 5.3 x 10 9 /l, MCV 112 fl and
platelet count was 89 x 10 9 /l. The reticulocyte
count was <0.0001%.

There was anisocytosis and poikilocytosis was
seen in the blood film.

What is the likely diagnosis?

1- Aplastic anaemia

2- Parvovirus infection

3- Myelodysplasia

4- Multiple myeloma

5- Waldenstrom's macroglobulinaemia

[Q: 2045] MRCPass-2010
September

Answer & Comments

Answer: 3- Myelodysplasia

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The myelodysplastic syndromes (MDS,
formerly known as "preleukemia") are a
diverse collection of hematological medical
conditions that involve ineffective production
of the myeloid cell lines.

The median age at diagnosis of a MDS is
between 60 and 75 years.

There is often pancytopenia as seen in this
case. A high MCV is common and a blood film
often shows poikilocytosis (which is in itself
non specific).

In this question, the answer is not aplastic
anaemia as the MCV is high.

[Q: 2046] MRCPass-2010
September

A 50 year old lady with chronic loin pains was
organised to have a intravenous urogram. This
revealed staghorn calculi. She had two
episodes or urinary tract infection in the last 3
years with Proteus identified in the urine
culture.

What is the predominant composition of these
calculi?

1- Uric acid

2- Manganese

3- Magnesium ammonium phosphate

4- Cystine

5- Calcium oxalate

Answer & Comments

Answer: 3- Magnesium ammonium phosphate

Upper urinary tract stones that involve the
renal pelvis and extend into at least 2 calyces
are classified as staghorn calculi.

Although all types of urinary stones can
potentially form staghorn calculi,

approximately 75% are composed of a
struvite-carbonate-apatite matrix. Struvite
(ammonium magnesium phosphate) is a
phosphate mineral with formula:

((NH4)MgP04*6H20). Struvite stones are
caused by bacterial infection that hydrolyzes
urea to ammonium and raises urine pH to
neutral or alkaline values. Urea-splitting
organisms include Proteus, Pseudomonas,
Klebsiella, Staphylococcus, and Mycoplasma.

A 65 year old man presents with shortness of
breath. He has a history of COPD and has
home oxygen and nebulisers. The ambulance
crew reported that they had given him high
flow oxygen and he is currently on 60%
oxygen. On examination, he is short of breath
but is able to have a conversation at present.
He has a respiratory rate of 20 and wheezing
throughout the lung. His arterial blood gases
on examination are:

pH 7.15 (7.36-7.44)

p02 15 (11.0-13.5) kPa

pC02 10 (3-6.0) kPa

HC03 28 (22-28)

BE-7 (-1 to 1)

What should be done?

1- Reduce to 24% oxygen

2- Continue at 60% oxygen

3- Intravenous theophylline

4- Non invasive ventilation

5- Intubation and ventilation

[Q: 2047] MRCPass-2010
September

Answer & Comments

Answer: 1- Reduce to 24% oxygen

This COPD patient has had too much oxygen
and is starting to C02 retain, causing a
respiratory acidosis.

The correct action is to reduce to 24% oxygen
in the first instance and initiate therapy for
COPD exacerbation, including steroids and
nebulisers. If he does not improve or
continues to worsen, then non invasive

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ventilation (BIPAP) or intubation should be
considered.

[Q: 2048] MRCPass - 2010
September

A 26-year-old presents a three month history
of amenorrhea. She had no other symptoms
but takes medication for contraception. Her
BMI is 23 and blood pressure is 120 / 80
mmHg. Examination reveals slight
galactorrhoea expression from both breasts
but otherwise normal. Blood tests revealed a
result for Prolactin 890 mll/L (< 450).

An MRI Scan was organised and this showed a
microprolactinoma with a 7 mm diameter.

Which one of the following hormones is likely
to be deficient?

1- Oestrogen

2- Growth hormone

[Q: 2049] MRCPass - 2010
September

A 70 year old man presents with left sided
facial drop and left hemiparesis. A CT scan
showed that he had a right middle cerebral
artery infarct and he was commenced on
dipyridamole.

What is dipyridamole's mechanism of action?

1- Phosphodiesterase inhibitor

2- Cyclooxygenase inhibitor

3- Glycoprotein llb/llla inhibitor

4- ADP antagonist

5- Low molecular weight heparin

Answer & Comments

Answer: 1- Phosphodiesterase inhibitor
The action of dipyridamole is on platelets.

3- Antidiuretic hormone

4- Thyroid hormone

5- Cortisol

Answer & Comments

Answer: 1- Oestrogen

Prolactinomas are the most common
hormone-secreting pituitary tumors.

Based on size, a prolactinoma can be classified
as a microprolactinoma (<10 mm diameter) or
macroprolactinoma (>10 mm diameter).
Prolactin inhibits gonadotrophin secretion.
The major effect of increased prolactin is a
decrease in levels of sex hormones - estrogen
in women and testosterone in men.
Symptoms due to a Prolactinoma include
amenorrhea, galactorrhea, loss of axillary and
pubic hair, hypogonadism and
gynecomastia(in males).

Inhibition of phosphodiesterase by
dipyridamole elevates platelet cAMP levels by
inhibiting its breakdow n. The high cAMP
levels lead to a reduction in intracellular Ca2+
and this inhibitsevents leading to platelet
activation and granule excretion.

I ft

A 36 year old man has injured his leg whilst
playing football.

Which one of the following is consistent with a
common peroneal nerve injury due to fibula
neck injury?

1- Loss of ankle jerk

2- loss of sensation over the lateral part of the
leg

3- Loss of dorsiflexion

4- Loss of sensation to the medial part of the
thigh

5- Loss of inversion

[Q: 2050] MRCPass-2010
September

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Answer & Comments

Answer: 3- Loss of dorsiflexion

There is foot drop, loss of dorsiflexion and
eversion of the foot in common peroneal
nerve injury.

Inversion and plantar flexion are normal.
There is usually sensory loss over the lower
lateral part of the leg and dorsum of the foot.

[Q: 2051] MRCPass - 2010
September

A 40 year old man is seeking advice. He has
adult polycystic kidney disease and has a
young son. He wants to know what is the
chance that his son has the disease.

In what percentage is the son likely to be
affected?

1 - 0 %

2- 25%

3- 50%

4- 75%

5- 100%

Answer & Comments

Answer: 3- 50%

There is no organomegaly in the abdomen. A
chest X ray shows hyperinflated lungs. Blood
results show : Hb 18.5 g/dl, WCC 14 x 10 9 /l,
platelets 350 x 10 9 /l. Haematocrit is 55%
(<48%).

What is the likely cause of this picture?

1- Primary polycythemia

2- Secondary polycythemia due to smoking

3- Polycythemia rubra vera

4- Methaemoglobinaemia

5- Congenital heart disease

Answer & Comments

Answer: 2- Secondary polycythemia due to
smoking

This patient is a heavy smoker and probably
has COPD.

Polycythaemia can be due to smoking can
cause plethora and a clinical picture as
described above.

There is no splenomegaly, which suggest that
polycythaemia rubra vera is unlikely. The
haematocrit (proportion of red cell mass to
plasma volume) is elevated in both primary
and secondary polycythaemias.

The patient has autosomal dominant
polycystic kidney disease.

This means he is likely to have one gene
affected and one unaffected. The likelihood of
the son inheriting one of these genes is 50%.

[Q: 2052] MRCPass - 2010
September

A 60 year old man has been complaining of
breathlessness. He is a long standing smoker
of 25 cigarettes a day.

On examination, he has a plethoric facies.
Cardiovascular examination is normal and the
breath sounds are clear.

[Q: 2053] MRCPass-2010
September

A 42 year old type I diabetic is referred for
renal investigations. She has been suffering
from Rheumatoid arthritis for the last 20
years. She is currently on insulin injections,
ibuprofen and penicillamine. She had
proteinuria on a urine dipstick and
quantification with 24 hour urine collection
revealed that she had urinary protein > 4.5
g/day.

Ultrasound of the abdomen shows increased
renal echogenicity. Investigations show :

Hb 11.5 g/dl

MCV 82 fl

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WCC 12 x 1071
platelets 225 x 10 9 /l
sodium 135 mmol/I
potassium 4.5 mmol/I
Urea 14 mmol/l
Creat 215 umol/l

A renal biopsy shows eosinophilic deposits
within the mesangium on light microscopy.
The basement membrane and epithelial space
is normal.

Whot is the probable diagnosis?

1- Minimal change nephropathy

2- Membranous nephropathy

3- Diabetic nephropathy

4- NSAIDS induced nephropathy

5- Amyloidosis

Answer & Comments

Answer: 5- Amyloidosis

Diabetic nephropathy is unlikely to cause such
heavy proteinuria, hence amyloidosis due to
rheumatoid arthritis is the most likely
diagnosis.

Amyloidosis is a clinical disorder caused by
extracellular and or intracellular deposition of
insoluble abnormal amyloid fibrils that alter
the normal function of tissues. AA amyloidosis
can be caused by rheumatoid arthritis. Up to
5% of patients with long-standing RA can
develop systemic amyloidosis that usually
presents as nephrotic syndrome. The biopsy
shows eosinophilic deposits in the mesangium
and capillary walls, which can be stained pink
with Congo Red.

Membranous nephropathy can present
similarly, but is more commonly associated
with autoimmune diseases (e.g. SLE),
infections (e.g. hepatitis B) and malignancy
(e.g. lymphoma).The drugs for rheumatoid
arthirits ie NSAIDS, penicillamine gold can
cause membranous nephropathy. The renal

biopsy will show small subepithelial deposits
in the glomeruli which can also lead to spikes
or thickening of the basement membrane but
the mesangium is typically normal.

This case is also unlikely to be minimal change
disease - (age of onset usually younger), the
histology shows in minimal change shows a
normal glomerulus and fusion of epithelial
foot process will be seen only on electron
microsocopy.

1 _ s

A 23 year old man has been bitten by a dog on
the thigh whilst walking in a park. 2 days later
he develops erythema around the site and a
purulent wound.

What is best antibiotic?

1- Trimethoprim

2- Metronidazole

3- Flucloxacillin

4- Ciprofloxacin

5- Augmentin

[Q: 2054] MRCPass-2010
September

Answer & Comments

Answer: 5- Augmentin

Pasteurella (canis or multicoda) species are
the most frequent isolates from both dog
bites.

Other common aerobes included streptococci,
staphylococci, moraxella, and neisseria.
Augmentin is the recommended antibiotic,
along with tetanus injection for prophylaxis. If
there is evidence of cellulites as in this case,
then fluclox and benpen should be prescribed.

[Q: 2055] MRCPass-2010
September

A 20-year-old lady with polycystic ovary
syndrome was prescribed Metformin.

How does Metformin acts in this situation?

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1- Increasing oestradiol levels

2- Increasing luteinising hormone levels

3- Increasing gluconeogenesis

4- Increasing insulin levels

5- Increasing peripheral glucose uptake

Answer & Comments

Answer: 5- Increasing peripheral glucose
uptake

Metformin is being used increasingly in
polycystic ovary syndrome (PCOS) and non¬
alcoholic steatohepatitis, two diseases that
feature insulin resistance.

Metformin improves insulin sensitivity by
increasing peripheral glucose uptake and
utilization. The reduction of hormonal
imbalance and treatment of insulin resistance
helps to restore the ovulatory cycles and
fertility in PCOS.

1 *I

A 75 year old lady presents with visual
problems and poor coordination. She
mentions that over the last two days, she
experienced a mild headache and visual
blurring. She found it difficult to dress herself.
There is a history of hypertension and type 2
diabetes. On examination, she has left
homonymous hemianopia. Tone and power
were normal, but she had a left sided loss of
sensation to the upper and lower limbs.

What is the likely site of lesion?

1- Posterior cerebral artery

2- Posterior inferior cerebellar artery

3- Inferior cerebral artery

4- Middle cerebral artery

5- Anterior cerebral artery

[Q: 2056] MRCPass-2010
September

Answer & Comments

Answer: 1- Posterior cerebral artery

The better answer is posterior cerebral artery,
as it the distribution affected by a stroke can
cause homonymous hemianopia, hemisensory
loss and also parietal lobe signs such as
apraxia.

In a middle cerebral artery lesion more
significant signs such as motor weakness
would be expected.

[Q: 2057] MRCPass-2010
September

A 57-year-old man with a history of
hypertension, diabetes, bipolar disorder and
chronic obstructive pulmonary disease.

He has bloods taken in clinic with the
following results:

sodium 119 mmol/l

potassium 3.8 mmol/l

Bicarbonate 26 mmol/l

Urea 3.7 mmol/l

Creatinine 92 pmol/l

Plasma osmolality 270 mosmol/l (275-290)
Urine osmolality 400 mosmol/l (350-1000)

Which one of the following medications is
most likely to be responsible?

1- Metformin

2- Lithium

3- Carbamazepine

4- Carbimazole

5- Pioglitazone

Answer & Comments

Answer: 3- Carbamazepine

This patient has hyponatraemia which is most
likely to be due to drug induced SIADH causes.

The reason the diagnosis is SIADH, is because
the urine osmolality is inappropriately high

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due to excess ADH causing concentrated
urine, despite hyponatraemia. An easy way to
remember certain drugs causing SIADH are
those starting with C:

■ carbamazepine

■ chlorpromazine

■ chlorpropramide
cyclophosphamide

[Q: 2058] MRCPass - 2010
September

A 30 year old lady is 32 weeks pregnant. This is
her second pregnancy, the first pregnancy was
uneventful. She has pruritus and on
examination, was mildly jaundiced. Liver
function tests showed:

ALT 75 (5-35) U/l
AST 70(1-31) U/l
ALP 350 (20-120) U/l
Bilirubin 70 (1-22) |imol/l
Albumin 38 (37-49) g/l

Gamma glutamyl transpeptidase 120 (<50)
U/L

What is the likely diagnosis?

1- Primary biliary cirrhosis

extremities, palms, and soles. The itching may
be severe, and it is often worse at night.
Jaundice develops in 20 to 60 percent of
women one to four weeks after the onset of
itching. The features of obstructive jaundice,
including pale stools and dark urine, may be
present, but patients do not have
constitutional symptoms. Intrahepatic
cholestasis is associated with an increased risk
of prematurity and stillbirth. Women with
intrahepatic cholestasis should be treated at
centers capable of caring for premature
infants. Cholestyramine, given in divided
doses totalling 10 to 12 g per day, may help
relieve pruritus.

A 25 year old man person attacks his girlfriend
and shows no remorse. His friend says that of
late he has become very aggressive. His
girlfriend says that he hasn't slept for 2 days.
On examination he is aggressive and is pacing
around a lot. He says he cannot be punished
as he has contacts with high level police
officials.

What is the diagnosis?

1- Paranoid schizophrenia

2- Mania

[Q: 2059] MRCPass-2010
September

2- Gallstones

3- Cholangiocarcinoma

4- Intrahepatic cholestasis of pregnancy

5- Viral hepatitis

Answer & Comments

Answer: 4- Intrahepatic cholestasis of
pregnancy

Intrahepatic cholestasis of pregnancy usually
presents during the third trimester, at a mean
of 30 weeks of gestation.

The characteristic symptom is itching (pruritus
gravidarum), which involves the trunk,

3- Psychotic depression

4- Conversion disorder

5- Anxiety disorder

Answer & Comments

Answer: 2- Mania

This man demonstrates increased levels of
activity, aggressiveness and restlessness
consistent with mania.

He also has abnormal unrealistic beliefs but
not psychotic features such as delusions or
hallucinations.

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[Q: 2060] MRCPass - 2010
September

A 55-year-old man with a history of epilepsy is
seen in the neurology clinic. Over the last few
months, he has experienced a 'numbness' of
his hands and feet. On examination he has
reduced sensation in a gloveand-stocking
distribution associated with a reduced ankle
reflex. On examination, he has
lymphadenopathy in the cervical and inguinal
region and some bleeding around the gums.

Which one of the following medications is he
most likely to hove been taking?

1- Carbamazepine

2- Phenytoin

3- Topiramate

4- Sodium valproate

5- Lamotrigine

Answer & Comments

Answer: 2- Phenytoin

Phenytoin side effects include gingival
hypertrophy, megaloblastic anaemia,
lymphadenopathy and peripheral neuropathy.

[Q: 2061] MRCPass-2010
September

A 65 year old man presents with a three
month history of fever, malaise, anorexia,
twenty-five pound weight loss, diffuse
myalgias and night sweats, and more recently
hemoptysis.

He had a past medical history of hypertension,
and described episodes of haematuria.
Physical examination showed that he had
diffuse lower extremity muscle tenderness,
crepitations in the lungs and a rash on the
trunks. Chest x-ray showed bilateral diffuse
pulmonary infiltrates and also 2 areas of
cavitation.

Investigations showed:
urine protein 1+

urine sediment - many red blood cell and
granular casts

sodium 135 mmol/I

potassium 5.2 mmol/l

urea 14 mmol/l

creatinine 220 [irnol/l

Whot investigation should be organised next?

1- Urine culture

2- Anti neutrophil cytoplasmic antibody

3- Renal biopsy

4- CT of kidney, ureter, bladder

5- MR angiogram of the kidneys

Answer & Comments

Answer: 2- Anti neutrophil cytoplasmic
antibody

The diagnosis fits a pulmonary renal syndrome
such as Wegener's, Churg Strauss or
Goodpasture's syndrome.

Apart from renal failure, there may be
pulmonary haemorrhage, haemoptysis,
infiltrates on the CXR as well as cavitation.

The least invasive method initially to confirm a
vasculitis is to request an ANCA.

[Q: 2062] MRCPass-2010
September

A trial assessed a statin tablet compared to
placebo for stroke prevention over 1 year.
There were 10% of patients developing stroke
in the group taking a tablet and 20% in the
carotid endarterectomy group developing a
stroke over the 1 year.

What is the number needed to treat over 1
year to prevent 1 death?

1- 1

2- 10

3- 20

4- 100

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5- 1000

Answer & Comments

Answer: 2-10

NNT is defined as number needed to treat to
prevent 1 death.

The way to work this out is 1 divided by
absolute risk reduction (Experimental event
rate - control event rate). Hence 1 / (ARR) is 1
/ 10% which is 10.

[Q: 2063] MRCPass - 2010
September

A 60 year old man with no previous symptoms
had a routine ECG. The ECG shows left bundle
branch block. The patient is currently taking
Aspirin 75 mg od. He has a family history of
myocardial infarction. He smokes 20
cigarettes a day. The GP is concerned and
refers the patient for further investigation. On
examination, BP is 120/70 mHg and there are
no findings during cardiovascular exam.

Which of the following investigations is
indicated?

appropriate to conduct a myocardial perfusion
scan.

[Q: 2064] MRCPass - 2010
September

A 50 year old lady is being reviewed in the
diabetes clinic. She has type 2 diabetes which
is poorly controlled and a history of CCF with
moderately impaired left ventricular function.
Her BMI is 35. She is currently on gliclazide

160mg bd, a long acting glargine insulin and
short acting actrapid insulin with meals,
frusemide, amlodipine and bendrofluazide.
Her HbAlc value is 12 and she has frequently
high BMS recorded. Her latest U&E results are
urea 10 mmol/l, creatinine 190 pmol/l.

What is the best medication to add to control
her blood sugars?

1- Rosiglitazone

2- Metformin

3- Exanetide

4- Glimepiride

5- Glucagon

1- Exercise ECG

2- CT of coronary arteries

3- Myocardial perfusion imaging

4- Coronary angiography

5- Cardiac MRI

Answer & Comments

Answer: 3- Myocardial perfusion imaging

For a patient with moderate likelihood of
coronary artery disease (this patient is not
symptomatic so is not in the high risk
category), non invasive testing such as
Exercise tolerance tests or myocardial
perfusion tests should be performed.

An exercise test will be difficult to interpret
due to the ECG changes of LBBB. Thus its most

Answer & Comments

Answer: 3- Exanetide

The newer incretin (GLP) analogues such as
exanetide and liraglutide are now included in
the guidelines by NICE CG 66 for patients who
have not responded to insulin and
Thiazolidinediones.

A 45 year old man is investigated for

[Q: 2065] MRCPass-2010
September

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hypertension. Despite being on 3 different
drugs, his blood pressure is consistently above
180/100 mmHg. Blood results show :

PH 7.5

P02 -13 kPa

PC02 - 4 kPa

bicarbonate 32 (20-28) mmol/l

sodium 138 mmol/l

potassium 2.7 mmol/l

urea 6 pmol/l

creatinine 100 |imol/l

Whot investigation should be requested?

1- 24 hour urine catecholamines

2- 24 hour urine HIAA

3- Renin aldosterone ratio

4- MRI of the adrenal glands

5- Selective venous sampling

[Q: 2066] MRCPass - 2010
September

A clinical trial studied patients' outcomes
before and after they were given an
antihypertensive drug.

Which one of these factors would invalidate
the use of a paired t test?

1- Not being in normal distribution

2- Small sample size

3- An underpowered study

4- Study bias

5- Loss to follow up

Answer & Comments

Answer: 1- Not being in normal distribution

The students t test can be used to compare
two groups of data (paired T test being an
example) with parametric data.

Answer & Comments

Answer: 3- Renin aldosterone ratio

Hypokalaemic alkalosis with refractory
hypertension as in this case suggests primary
hyperaldosteronism (Conn's syndrome).

Parametric means that the data will be of
normal distribution and parallels the normal
or bell curve). In this case if the data was not
of normal distribution, t tests cannot be used
and a non parametric test such as Kruskal
Wallis or Wilcoxon test should be used
instead.

Secondary hyperaldosteronism would also be
possible but tends to cause hypertension
which is easier to control. As Conn's is caused
by high aldosterone due to an aldosterone
secreting tumour, the high aldosterone
enhances exchange of sodium for potassium
in the kidney so there is hypernatremia and
hypokalemia.

The sodium retention leads to plasma volume
expansion and elevated blood pressure. The
increased blood pressure will lead to
increased glomerular filtration rate and cause
a decrease in renin release from the granular
cells of the juxtaglomerular apparatus in the
kidney. Usually, renin levels are suppressed,
leading to a very low renin-aldosterone ratio
(<0.0005).

[Q: 2067] MRCPass - 2010
September

A 41-year-old female patient, an ex-smoker
with an 8-pack-year smoking history and
severe pulmonary emphysema of early onset,
received a diagnosis of 1-antitrypsin (AAT)
deficiency. Regarding alpha 1 antitrypsin
phenotypes, which of the following is most
strongly associated with emphysema?

1- ZZ

2- MZ

3- SZ

4- MM

5- SS

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Answer & Comments

Answer: 1- ZZ

The commonest phenotype is Protease
Inhibitor (Pi)MM (90% of the population have
this).

These individuals produce normal amounts of
alphal-antiprotease. The most common form
of alpha 1 antitrypsin deficiency is associated
with allele Z, or homozygous PiZ (ZZ). Serum
levels of AAT in these patients are about 3 - 7
umol/L (10-15% of normal serum levels).
Emphysema develops in most (but not all)
individuals with serum levels less than 9
mmol/L.

PiMM: 100% (normal)

PiMS: 80% of normal serum level of A1AT

PiSS: 60% of normal serum level of A1AT

PiMZ: 60% of normal serum level of A1AT

PiSZ: 40% of normal serum level of A1AT

PiZZ: 10-15% (severe alpha 1-antitrypsin
deficiency)

3- Central retinal artery thrombosis

4- Central retinal vein thrombosis

5- Diabetic retinopathy

Answer & Comments

Answer: 2- Anterior ischaemic optic

neuropathy

The diagnosis is Temporal arteritis (Giant Cell
Arteritis).

Around 50% of patients with GCA eventually
experience visual symptoms (eg, transient
visual blurring, diplopia, eye pain, sudden
vision loss). Transient repeated episodes of
blurred vision are usually reversible, but
sudden loss of vision is an ominous sign and is
almost always permanent. The most common
cause of vision loss is anterior ischemic optic
neuropathy (AION). This results from ischemia
of the optic nerve head, supplied mainly by
the posterior ciliary arteries. Examination of
the fundus may reveal optic disc edema, with
or without splinter hemorrhages along the
disc margin.

[Q: 2068] MRCPass - 2010
September

A 70-year-old female presented with sudden
onset loss of vision in the left eye. Her past
medical history includes hypertension,
diabetes, polymyalgia and hypothyroidism.
She had a headache on the left. On
examination, she had temporal artery
tenderness on the left. The patient's
erythrocyte sedimentation rate (ESR) was 120
and her blood pressure is 150/90 mmHg.
Fundoscopy revealed optic disc oedema with
splinter haemorrhages around the optic disc
on the left.

What is the most likely couse of her visual
loss ?

1- Hypertensive retinopathy

2- Anterior ischaemic optic neuropathy

[Q: 2069] MRCPass - 2010
September

Whot is the likely physiological action of
Gastrin?

1- Luminal peptides stimulates its release in
the gastric antrum

2- Somatostatin stimulates its release in the
gastric antrum

3- Acts on G cells in antrum

4- reduces pancreatic bicarb secretion

5- Reduces gastric blood flow

Answer & Comments

Answer: 1- Luminal peptides stimulates its
release in the gastric antrum

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In humans, gastrin is a hormone that
stimulates secretion of gastric acid by parietal
cells in the stomach.

It is released by G cells in the stomach antrum
and duodenum (it doesn't act on G cells).

Gastrin release is stimulated by:

stomach distension
vagal stimulation

the presence of partially digested
proteins especially amino acids

Gastrin release is inhibited by:

Increased acidity
Somatostatin

[Q: 2070] MRCPass - 2010
September

A 28 year old female took 40 tablets of
Paracetamol and was admitted to hospital.
She is seen the following day and needs
assessment of her medical condition.

Which of the following is the best investigation
to assess prognosis after 26 hours for a
paracetamol overdose?

1- Prothrombin time

2- AST

3- Paracetamol level

4- Urea and creatinine

5- Bilirubin

Answer & Comments

Answer: 1- Prothrombin time

Although all of the tests may be abnormal, the
INR / prothrombin time measurement is the
most important in predicting prognosis (part
of the child pugh criteria for liver failure) after
a paracetamol overdose.

[Q: 2071] MRCPass-2010
September

A 55-year-old man presented with a 10 -year
history of an intermittent rash and pruritus
associated with sweating from exertion.

For 2 years he had noted pruritus and
erythema mainly in the hands and feet,
occurring on exposure to cool weather and
resolving promptly on warming. He has a past
medical history of Investigations showed a
normal full blood count and mildly deranged
liver function tests. Cryoglobulin levels were
elevated.

Which one of the following is likely to be
positive?

1- Rheumatoid factor

2- Antinuclear antibody

3- Anti neutrophil cytoplasmic antibody

4- Anti centromere antibody

5- Anti Ro and La antibody

Answer & Comments

Answer: 1- Rheumatoid factor

Cryoglobulinaemia occurs when there are
large amount of proteins that become
insoluble at reduced temperatures.

Type I is most commonly encountered in
patients with multiple myeloma.Types II and
III are strongly associated with infection by the
hepatitis C virus.

Types II and III have Rheumatoid Factor
activity and bind to polyclonal
immunoglobulins.

Cryoglobulins may also be present in
mycoplasma pneumonia, leukemias, primary
macroglobulinemia, and some autoimmune
diseases, such as systemic lupus
erythematosus and rheumatoid arthritis.

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[Q: 2072] MRCPass - 2010
September

A 30-year-old man presents with sever
abdominal pains. His blood tests and
abdominal examination were normal.

He had recently had an ultrasound of the
abdomen which did not identify any
pathology. It was noticed that he had multiple
scars on his upper limb. He also kept asking
for opiate drugs for pain relief.

What is the likely diagnosis?

1- Malingering

2- Hypochondriasis

3- Factitious disorder

medically unexplained symptoms. The
patient's life or work are frequently affected,
although they also might be unconcerned
about the nature of their symptoms (thus
appearing calm). It is not a deliberate feigning
of symptoms.

Conversion disorder : (somatoform

4- Somatisation disorder

5- Conversion disorder

Answer & Comments

Answer: 1- Malingering

The different common psychiatric diagnoses
are below .

In this case it seems that the patient is
malingering in order to obtain narcotic drugs
(evidence of intravenous injection marks on
the limbs).

Munchausen syndrome (factitious disorder):
the patient seeks medical attention by the
deliberate production or feigning of
symptoms. The motivation for seeking
attention is not known.

Somatisation disorder:(somatoform disorder)
With this a patient presents with multiple,

[Q: 2073] MRCPass-2010
September

A 50 year old lady with fever, fatigue and
anaemia has been diagnosed as having acute
myeloid leukaemia. On examination, she is
pale and has mild splenomegaly.

Which one of the following is the strongest
determinant of prognosis?

1- White cell count

2- Number of blast cells with bone marrow

3- Morphology of cells

4- Size of spleen

5- Karyotype

Answer & Comments

Answer: 5- Karyotype

Acute myeloid leukemia (AML), also known as
acute myelogenous leukemia, is the most
common acute leukemia affecting adults.

Anaemia, fever, weight loss, bleeding
(thrombocytopenia) and also infections can be
presenting symptoms. According to the widely
used WHO criteria, the diagnosis of AML is
established by demonstrating involvement of
more than 20% of the blood and/or bone

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marrow by leukemic myeloblasts. There are 8
subtypes.

Patients with AML can have high, normal, or
low WBC counts.

The single most important prognostic factor in
AML is cytogenetics, or the chromosomal
structure of the leukemic cell. Cytogenetic
karypotypes e.g. t(15;17), t(8;21) and

inv/del/t(16) are associated with good
prognosis. Because acute promyelocytic
leukemia (APL) has the highest curability and
requires a unique form of treatment, it is
important to quickly establish the diagnosis,
particularly the t(15;17) translocation.

A number of other cytogenetic abnormalities
are known to associate with a poor prognosis:
5, -7, del(5q), Abnormal 3q, Complex

cytogenetics.

Age >60 years and elevated lactate
dehydrogenase level are also associated with
poorer outcomes in AML

[Q: 2074] MRCPass-2010
September

A 37-year-old patient presents with a painless
skin lesion on his left finger, first observed 5
days before admission. On examination, a
purulent looking pustule of 1 cm diameter was
seen. The patient reported that he was
working on a sheep farm.

What is the diagnosis?

1- Staphylococcal furuncle

2- Cutaneous anthrax

3- Chickenpox

4- Leprosy

5- Orf

Answer &. Comments

Answer: 5- Orf

Orf is an exanthemous disease caused by a
parapox virus and it also known as Ecthyma

contagiosum.

It is a zoonosis usually transmitted to humans
from affected sheep or goat through direct
contact or contaminated fomites. There are
typically no systemic symptoms.

The papule may persist for 7 to 10 weeks and
spontaneously resolves. Whilst treatment is
mainly conservative, some cases have
improved with topical antiviral agents.

ORF

A 35 year old turkish woman presents with a 2
month history of intermittent fevers
associated with cutaneous pallor, weight loss,
vomiting and anorexia. Physical examination
revealed an enlarged liver (4.5 cm from the
right costal margin) with smooth borders, a
soft palpable spleen (6 cm from the left costal
margin). The following results were obtained:

Hb 7.5 g/dl

MCV 75 fl

WCC 3 x 10 9 /l

platelets 54 x 10 9 /l

sodium 135 mmol/l

potassium 4.5 mmol/l

urea 5 mmol/l

creatinine 85 mmol/l

What is the likely diagnosis?

1- Malaria

2- Non Hodgkin's lymphoma

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September

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3- Tuberculosis

4- Visceral leishmaniasis

5- Schistosomiasis

Answer & Comments

Answer: 4- Visceral leishmaniasis

There are several forms of leishmaniasis,
cutaneous and visceral are commonly quoted.

In this case, fever and hepatosplenomegaly
would be consistent with visceral
leishmaniasis. Bone marrow infiltration may
cause anemia, thrombocytopenia, and
leukopenia. The gold standard for diagnosis is
visualisation of the amastigotes in the bone
marrow aspirate. Leishmania donovani can be
spread by the sandfly. The traditional
treatment is with pentavalent antimonials
such as sodium stibogluconate (many resistant
cases in India), but increasingly amphotericin
B is the preferred treatment in depending on
geography.

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[ Q: 2076 ] MRCPass - 2011 January

A 55-year-old man, known to have
hepatitis C, was admitted with lethargy and
diffuse petechial rash of the lower extremities.
The rash had been present for the previous 2
months, starting as a macular rash in both
lower extremities and progressing to involve
the trunk and upper extremities. The following
investigation results were obtained:

Urinalysis showed microscopic hematuria with

3-6 coarse granular casts, and proteinuria +++.

Hb 8.5 g/dl

MCV 85 fl

WCC 8 x 10 9 /l

platelets 170 x 10 9 /l

sodium 135 mmol/I

potassium 4.5 mmol/I

urea 24 mmol/l

creatinine 355 |imol/l

C3 = 52 mg/dL (79-152)

C4 = 3.5 mg/dL (16-38)

Rheumatoid factor was 150 lU/mL (normal: 0-
20 )

Whot is the diagnosis?

1- Haemolytic uraemic syndrome

2- Crescentic glomerulonephritis

3- Autoimmune haemolytic anaemia

4- Henoch Schonlein purpura

5- Cryoglobulinemia

Answer & Comments

Answer: 5- Cryoglobulinemia

Cryoglobulins are serum proteins that
precipitate in the cold.

It is classified into three types (I, II and III),
type II and III usually associated with hepatitis
C virus (HCV) infection. In chronic HCV
infection, cryoglobulins are found in 80% of
patients of whom 10% develop

cryoglobulinemic vasculitis. The clinical
manifestations are as described in this
scenario, with cutaneous vasculitis (skin
lesions are usually palpable purpura of the
lower extremities) and renal impairment
(cryoglobulin deposits in the renal glomeruli
leading to proteinuria) in the form of
glomerulonephritis.

[ Q: 2077 ] MRCPass - 2011 January

A 31 year old man with a 15 year
history of type 1 diabetes presents with a 4
month history of pain and stiffness of the left
shoulder. On examination, he has limited
internal rotation and abduction of the
shoulder.

What is the likely diagnosis?

1- Osteoarthritis

2- Rheumatoid arthritis

3- Brachial neuropathy

4- Adhesive capsulitis

5- Glenohumeral menisceal tear

Answer & Comments

Answer: 4- Adhesive capsulitis

The features of reduced internal rotation and
abduction are typical of frozen shoulder /
adhesive capsulitis.

In this condition, the connective tissue
surrounding the glenohumeral joint of the
shoulder, becomes inflamed and stiff leading
to limited movement and pain. The movement
of the shoulder is severely restricted and the
pain is usually constant, worse at night.
Treatment is with analgesia (NSAIDS) and
physiotherapy. In more severe cases, steroid
injections or surgery (capsular release) may be
necessary.

[ Q: 2078 ] MRCPass - 2011 January

A 53 year old man presented to the
emergency department with a collapse. He

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was found at home unwell by his wife. He had
a past medical history of TIA, a type II
diabetes, and depression. His medications
were gliclazide and aspirin. On examination he
was afebrile and his BM was 9.0. His GCS was
8 (E2, V3, M3). He had no neck stiffness. His
pupils were pinpoint and there was a lack of
horizontal gaze. He had bilateral upgoing
plantar reflexes, increased tone throughout,
and brisk reflexes.

What is the diagnosis?

1- Posterior inferior cerebellar stroke

2- Demyelination

3- Pontine haemorrhage

4- Middle cerebral artery lesion

5- Posterior communicating artery aneurysm

Answer & Comments

Answer: 3- Pontine haemorrhage

Large pontine haemorrhage lesions can
Quadriplegia, coma, small reactive pupils and
bilateral paralysis of horizontal conjugate gaze
are typical sequelae.

There is often downward eye movements -
ocular bobbing - imply preservation of rostral
brainstem gaze centres.

Smaller unilateral basal pontine lesions can
present with contralateral hemiparesis, often
with ataxia in the limbs affected.

[ Q: 2079 ] MRCPass - 2011 January

A 30 year old man has had Hepatitis
B testing. He mentioned that he previously
had Hepatitis B immunisation.

Which one of the following is likely to be
positive indicating effective immunisation?

1- Hep B s Antigen

2- Hep B c Antigen

3- Hep B e Antigen

4- Hep B s Antibody

5- Hep B c Antibody

Answer & Comments

Answer: 4- Hep B s Antibody

A chronic carrier has positive Hep B s Ag and
positive HepB c Ab

A patient with previous immunization has Hep
B s Ag negative and negative Hep B c Ab and
positive HepBs Antibody, (note that the core
antibody is non specific and not elevated post
immunisation)

A patient with previous Hep B infection who is
not a chronic carrier, has negative Hep B s Ag
and positive HepBc

Antibody and positive HepBs Antibody (both
antibodies are positive)

[ Q: 2080 ] MRCPass - 2011 January

A 57 year old man was admitted to
another hospital with frequent bloody
diarrhea (10-15 bow el motions/day),
abdominal pain, and fever. On admission,
physical examination showed a temperature
of 37.5°C; the abdomen was soft, but there
was moderate tenderness in the lower
abdomen. Laboratory results showed mild
anemia (haemoglobin, llg/dl), albumin 32
(37-49) g/l, elevated C-reactive protein
57mg/dl. A colonoscopy was performed.

This showed aggregates of yellow -whitish,
well defined plaque in the ascending colon to
the caecum. There was uniform congestion,
oedema and irregular shallow ulcers, crypt
abscesses and depletion of goblet cells.

What is the diagnosis?

1- Celiac disease

2- Crohn's disease

3- Ulcerative colitis

4- Clostridium difficile colitis

5- Enteroviral colitis

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Answer & Comments

Answer: 3- Ulcerative colitis

The history of bloody diarrhea is typical of
ulcerative colitis.

The biopsy specimen showing uniform areas
of inflammation rather than skip lesions, and
also crypt abscesses (these are crypts
infiltrated with leukocytes) are typical.
Typically, ulcerative colitis involves only the
mucosa, with the formation of crypt abscesses
and a coexisting depletion of goblet cell
mucin.

[ Q: 2081 ] MRCPass - 2011 January

A 36-year-old woman was evaluated
in outpatients following a complaint of visual
dificulties and an ophthalmologic evaluation
showed bitemporal hemianopia. An urgent
MRI scan was requested.

Where is the likely lesion?

1- Optic nerve

2- Optic chiasm

3- Optic radiation

[ Q: 2082 ] MRCPass - 2011 January

A 25 year old man has presented
with a primary pneumothorax for the first
time. He smokes 5 cigarettes a day.

The pneumothorax was aspirated and has
resolved when the CXR was repeated. He is
seeking advice about further management.

Which one of the following should he avoid?

1- No restrictions

2- Travelling by plane for 3 months

3- Travelling by plane indefinitely

4- Diving for 3 months

5- Diving indefinitely

Answer & Comments

Answer: 5- Diving indefinitely

These guidance is within the British Thoracic
society guidelines for pneumothorax.

Commercial airlines and BTS guidelines
currently advise that there should be a 6 week
interval between having a pneumothorax and
travelling by air.

4- Occipital lobe

5- Oculomotor nerve

Answer & Comments

Answer: 2- Optic chiasm

Bitemporal hemianopia is typically caused by
an optic chiasm lesion.

Since the adjacent structure is the pituitary
gland, some common tumors causing
compression are pituitary adenomas and
craniopharyngiomas. Another relatively
common neoplastic etiology is meningiomas.
In addition, an anterior communicating artery
aneurysm which arises superior to the chiasm
can enlarge, and compress it from above.

After a pneumothorax, diving should be
discouraged permanently unless a very secure
definitive prevention strategy such as surgical
pleurectomy has been performed.

[ Q: 2083 ] MRCPass - 2011 January

A man presents to the hospital with
severe vomiting and dirrhoea. On
examination, he was dehydrated, and his face
was flushed. He gives a history of drinking
wine and eating tuna as a main course in a fish
restaurant.

What is the likely cause?

1- Clostridium difficile toxin

2- Cholera toxin

3- Scrombrotoxin

4- Alfatoxin

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5- Celiac disease

Answer & Comments

Answer: 3- Scrombrotoxin

Scombroid food poisoning is a foodborne
illness that results from eating spoiled
(decayed) fish.

Answer: 2- Common bile duct

This patient demonstrates obstructive
jaundice and pancreatitis, and hence is likely
to have a form of obstruction lower down in
the biliary tree which is likely to be due to
gallstones.

Scrombotoxin is produced by oily fish such as
mackerel, tuna, mahi-mahi, bonito, sardines,
anchovies. Unlike many types of food
poisoning, this form is not brought about by
ingestion of a bacterium or virus. Histidine
exists naturally in many types of fish, and at
temperatures above 16°C (60°F) on air contact
it is converted to the biogenic amine
histamine via the enzymes in the fish. The
effects of histamine lead to nausea, diarrhoea
and flushing. Symptoms usually last for 4 -6

Esophagus

Liver left lobe

Liver nght Lobe

R>gtt8,u#l

Hepatic duct

Cystic

duct

Gall

bladder

Falciform

ligament

Stomach

— Common
Hepatic duct

Pancreatic

duct

...

Pancreas

Common bile
duct

hours.

Biliary Anatomy

I A

[ Q: 2084 ] MRCPass - 2011 January

[ Q: 2085 ] MRCPass - 2011 January

A 55-year-old female patient was

A 45 year old man presents with

referred to the emergency department with a
one-w eek history of epigastric pain, poor food
intake and pains radiating to her back, nausea
and vomiting. She also complained of dark
urine and jaundice, and her faeces become
pale. The following blood results were
obtained:

ALT: 127 U/L ( 5-40 U/L)

painful groin area and fevers.

He had no known past medical history but was
a frequent traveller. A month ago, he had
returned from India and following a month's
trip. He describes having a painless penile
ulcer 2 weeks ago. On examination, he had
palpable painful inguinal lymph nodes. The
blood results are:

alkaline phosphatase: 1300 U/l ( 98-290 U/L)

Bilirubin 85 (1-22) |imol/l

serum amylase: 2100 U/L (<220U/I)

Where is the likely site of obstruction leading
to jaundice?

1- Cystic duct Left hepatic duct

2- Common bile duct

3- Left hepatic duct

4- Right hepatic duct

5- Pancreatic duct

Hb 11.5 g/dl
MCV 82 fl
WCC 8 x 10 9 /l
platelets 330 x 10 9 /l
Blood cultures - no growth
Filarial serology- negative
Chlamydia serology- positive
Monospot test - negative
What is the likely diagnosis?
1- HIV infection

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2- Primary syphillis

potassium 5.8 mmol/l

3- Lymphogranuloma venereum

urea 6 mmol/l

4- Chancroid

5- Mycobacterium leprae infection

Answer & Comments

Answer: 3- Lymphogranuloma venereum

Lymphogranuloma venereum (LGV) is
primarily an infection of the lymphactic
system.

Chlamydia trachomatis is the bacteria
responsible for LGV. It gains entrance through
breaks in the skin, or the mucous membranes.
LGV may begin as a self-limited painless
genital ulcer that occurs at the contact site 3-
12 days after infection. This is followed by the
secondary stage most often occurs 10-30 days
later. The infection spreads to the lymph
nodes through lymphatic pathw ays causing
lymphangitis and painful lymphandenopathy.
Diagnosis is made with Chlamydia serology or
PCR of aspirate / pus samples. Treatment is
with tetracyclines or erythromycin.

The chancroid (a sexually transmitted disease)
can also present with painful inguinal
lymphadenopathy and genital ulcers. It does
not fit the scenario as Haemophilus ducreyi is
the infective organism. Treatment is with a
macrolide (erythromycin) or ceftriaxone.

[ Q: 2086 ] MRCPass - 2011 January

A 35 year old woman was admitted
to hospital with profuse diarrhoea over
several weeks. She had symptoms which
started 6 months ago. The diarrhoea was
watery and did not have mucus. The
symptoms also included nausea, poor appetite
and lethargy. On examination, she had a blood
pressure of 95 /60 mmHg. She looked
relatively well. There was no positive
examination findings. Blood test results were:

sodium 135 mmol/l

creatinine 90 |imol/l
ALT 30 (5-35) U/l
AST 25 (1-31) U/l
ALP (20-120) U/l
Bilirubin 13 (1-22) pmol/l
Albumin 32 (37-49) g/l
Glucose 5.5 mmol/l
What is the likely diagnosis?

1- Celiac disease

2- Adrenal insufficiency

3- Crohn's disease

4- Norovirus infection

5- Anorexia nervosa

Answer & Comments

Answer: 2- Adrenal insufficiency

This patient is likely to be Addisonian due to
features of hypotension, lethargy, diarrhoea
and mild hyperkalaemia (due to low
aldosterone levels).

[ Q: 2087 ] MRCPass - 2011 January

A 75 year old woman was referred
with a two-month history of generalised
weakness, fever, and weight loss.

There was no other relevant past medical
history.

On examination she had multiple petechiae
present on observation. There was no
palpable splenomegaly.

The blood results showed:

Hb was 9.5 g/dl, white cell count 5.3 x 10 9 /l,
MCV 112 fl and platelet count was 89 x 10 9 /l.
The reticulocyte count was <0.0001%. There
was anisocytosis and poikilocytosis was seen
in the blood film.

What is the likely diagnosis?

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1- Aplastic anaemia

2- Parvovirus infection

3- Myelodysplasia

4- Multiple myeloma

5- Waldenstrom's macroglobulinaemia

Answer & Comments

Answer: 3- Myelodysplasia

The myelodysplastic syndromes (MDS,
formerly known as "preleukemia") are a
diverse collection of hematological medical
conditions that involve ineffective production
of the myeloid cell lines.

The median age at diagnosis of a MDS is
between 60 and 75 years.

There is often pancytopenia as seen in this
case. A high MCV is common and a blood film
often shows poikilocytosis (which is in itself
non specific).

In this question, although the picture of the
blood tests is of a pancytopenia, the answer is
unlikely to be aplastic anaemia as the MCV is
high.

[ Q: 2088 ] MRCPass - 2011 January

A 40 year old man presented with
epigastric pains and indigestion. He had an
upper Gl endoscopy which showed
oesophagitis and gastritis. A biopsy was taken
which showed positive H pylori result and he
was commenced on 1 week of triple therapy
for eradication.

How should the eradication be monitored
now?

1- Repeat OGD for surveillance

2- Repeat OGD with biopsy

3- 14 C Breath test

4- H pylori serology

5- No further monitoring

Answer & Comments

Answer: 3-14 C Breath test

With the breath test, patients sw allow urea
labelled with an uncommon isotope,
radioactive carbon-14.

In the subsequent 10-30 minutes, the
detection of isotope-labelled carbon dioxide in
exhaled breath indicates that the urea was
split; this indicates that urease (H. pylori uses
to metabolize urea) is present in the stomach.
This is a useful non invasive test for
monitoring whether eradication is successful.

[ Q: 2089 ] MRCPass - 2011 January

A 34-year-old man presents with a
dry cough and shortness of breath. He has
typically experienced these dry cough
episodes twice a week. He has worked as a
spray paint worker in a car factory for 5 years.
He does not smoke nor drink any alcohol. On
examination, the patient was febrile (39°C),
and a clinical lung examination showed diffuse
crackles. A chest radiograph showed
interstitial infiltrates and bilateral hilar
adenopathy.

Pulmonary function tests were performed.

The results were (predicted percentages):

Forced vital capacity (FVC) 1.8 L (60%)

Forced expiratory volume (FEV1)1.7 L (70%)

FEV1/FVC ratio - 90%

Forced expiratory time (FET) 9.2 sec

Residual volume (RV) 0.8 L (40%)

Total lung capacity (TLC) 2.7 L (50%)

Diffusing capacity (DLCO) Hg 8.7 mL/min/mm
Hg (38%)

What is the likely diagnosis?

1- Asthma

2- Chronic obstructive pulmonary disease

3- Bronchiolitis obliterans organising
pneumonia

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4- Sarcoidosis

5- Hypersensitivity pneumonitis

Answer & Comments

Answer: 5- Hypersensitivity pneumonitis

Extrinsic allergic alveolitis (hypersensitivity
pneumonitis) results from hypersensitivity
immune reactions to the repeated inhalation
or ingestion of various antigens derived from
fungal, bacterial, animal protein, or reactive
chemical sources such as dust or paint.

are often used in the staging of non-Hodgkin's
lymphoma and Hodgkin's lymphoma.

[ Q: 2091 ] MRCPass - 2011 January

A 20 year old lady came to you with
a history of intermittent diarrhea.

A biopsy taken during colonoscopy revealed
melanosis coli.

What is the most likely cause for the biopsy
finding?

1- Crohn's disease Celiac disease

They can also present subacutely with
recurrent pneumonia or chronically with
exertional dyspnea, productive cough, and
weight loss. CXR and High resolution CT often
show upper zone pulmonary fibrosis. Lung
function tests often show a restrictive picture,
with decreased lung capacity and increased
FEV1/FVC ratio as demonstrated in this case.
The treatment is to reduce exposure to the
allergenic component, in this case paint
(isocyanates), and exacerbations can be
improved with a course of steroids.

2- Celiac disease

3- Ferrous sulphate use

4- Laxative overuse

5- Ulcerative colitis

Answer & Comments

Answer: 4- Laxative overuse

Melanosis coli is a disorder of pigmentation of
the wall of the colon, identified at the time of
colonoscopy.

[ Q: 2090 ] MRCPass - 2011 January

A 74-year-old man with a history of
non hodgkin's lymphoma of the nodular
sclerosing type has previously had
radiotherapy. He is complaining of lethargy.

Which one of the following symptoms
indicates poor prognosis?

1- Weight gain

2- Palpitations

3- Anxiety

4- Night sweats

5- Lethargy

Answer & Comments

Answer: 4- Night sweats

The B symptoms - fevers, night sweats and
weight loss - indicate a poorer prognosis and

It is benign, and has no significant correlation
with disease. The name is considered a
misnomer: the brow n pigment seen in the
colon is actually lipofuscin, not melanin as the
name implies.

The most common cause of melanosis coli is
the surreptitious use of laxatives, and
commonly anthraquinone containing laxatives
such as Senna and other plant glycosides.
Endoscopically, the mucosa shows a brownish
discoloration.

[ Q: 2092 ] MRCPass - 2011 January

A 47-year-old man presents with
palpitations which he has had for 3 months.
He feels his 'heart race' regularly.

On examination his pulse is 110 / min,
irregularly irregular and respiratory
examination is unremarkable
confirms atrial fibrillation.

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What is the most appropriate next step in
management?

1- Digoxin

2- Electrical cardioversion

3- Amiodarone

4- Metoprolol

5- Flecainide

Answer & Comments

Answer: 4- Metoprolol

In uncomplicated atrial fibrillation a beta
blocker should be used first line for rate
control and maintenance of sinus rhythm if
the patient has paroxysmal AF.

Flecainide would be a good second line option
if AF wasn't adequately controlled.

http://www.nice.org.uk/nicemedia/pdf/CG03

6niceguideline.pdf

[ Q: 2093 ] MRCPass - 2011 January

A 45 year old lady presents with
lethargy and nausea. Her blood results are
listed below :

Hb 12.5 g/dl

MCV 75 fl

WCC 8 x 10 9 /l

platelets 215 x 10 9 /l

sodium 135 mmol/I

potassium 4.5 mmol/I

urea 8 mmol/I

creatinine 90 pmol/l

calcium 1.7 (2.25-2.7) mmol/I

phosphate 0.9 (0.8-8) pmol/l

magnesium 0.8(0.67-0.96) mmol/I.

Which one of the following findings on her ECG
is probable?

1- Tall T wave

2- ST depression

3- Prolonged QT

4- Short PR interval

5- Reciprocal changes

Answer & Comments

Answer: 3- Prolonged QT

Hypocalcaemia is the main biochemical
finding on the blood results in this patient.

The electrolyte causes of prolonged QT are
hypokalaemia, hypocalcaemia and
hypomagnesaemia.

[ Q: 2094 ] MRCPass - 2011 January

A 35 year old lady presents with
palpitations. She has no significant past
medical history and does not take regular
medications. Her BP was 120 / 70 mmHg and
she had a heart rate of 180 bpm. An ECG
confirms a narrow complex tachycardia. She
was given 6 mg of adenosine with no clinical
effect to the heart rate.

What should be administered next?

1- DC cardioversion

2- Intravenous amiodarone

3- Adenosine 12 mg

4- Bisoprolol 5 mg

5- Digoxin 125 meg

Answer & Comments

Answer: 3- Adenosine 12 mg

The patient with rapid narrow complex
tachycardia is likely to have supra ventricular
tachycardia.

This may be cardioverted by adenosine which
blocks conduction at the AV node. The dose of
adenosine in this case has to be optimal
before trying a second option. 6 mg is unlikely
to be adequate and a step up to 12 mg or
even 18 mg may be necessary to cardiovert
the patient from the SVT to sinus rhythm.

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[ Q: 2095 ] MRCPass - 2011 January

A 46 year old woman presents with
fevers, night sweats, arthralgia. The urine
dipstick showed blood ++ and protein +. On
examination, her BP was 110 / 70 mmHg. She
had a systolic and diastolic murmur in the
aortic area and endocarditis was suspected.
An urgent echocardiogram confirmed
bacterial vegetations on the aortic valve.

Which one of the following is on indicotion for
urgent surgery?

1- Aortic regurgitation

2- Cardiac failure

3- Prolongation of PR interval on the ECG

4- Pyrexia

5- Renal impairment

Answer & Comments

Answer: 3- Prolongation of PR interval on the
ECG

In aortic valve endocarditis, prolongation of
the PR interval or AV dissociation is a feature
of possible aortic root abscess (due to the
position of the cardiac conduction system).

This is an indication for urgent surgery.

Answer & Comments

Answer: 5- Co-amoxiclav

Pasteurella (canis or multicoda) species are
the most frequent isolates from both dog
bites.

[ Q: 2097 ] MRCPass - 2011 January

An 20 year old patient is suspected
presents with a 6 month history of lethargy
and weight gain. She has a BMI of 30. On
examination, she looked obese and has
abdominal striae. Her Blood pressure is 125 /
90 mmHg. Blood tests show these results:
sodium 135 mmol/I, potassium 3.4 mmol/l,
urea 5 mmol/l, creatinine 100 pmol/l.

Whot is the investigation of choice?

1- Low dose dexamethasone suppression test

2- High dose dexamethasone suppression test

3- CRH test

4- Serum ACTH levels

[ Q: 2096 ] MRCPass - 2011 January

A 23 year old man has been bitten by
a dog on the thigh whilst walking in a park. 2
days later he develops erythema around the
site and a purulent wound.

5- Inferior petrosal sinus sampling

Answer & Comments

Answer: 1- Low dose dexamethasone
suppression test

Whot is best antibiotic to prescribe?
1- Trimethoprim

This patient is likely to have Cushing's
syndrome.

2- Metronidazole

3- Flucloxacillin

4- Ciprofloxacin

5- Co-amoxiclav

Failure of suppression of cortisol with low
dose dexamethasone over 2 days confirms
Cushing's syndrome. The high dose
suppression test is often used to determine
likelihood of pituitary dependent Cushing's
disease.

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[ Q: 2098 ] MRCPass - 2011 January

/ -

# A 60-year-old, man was admitted to

a hospital for the evaluation of a left adrenal
mass detected by abdominal ultrasonography.
He had no known history of hypertension,
diabetes mellitus, and other systemic
diseases.

Abdominal magnetic resonance imaging
showed a 54 x 50 x 46 mm mixed cystic and
solid mass arising from the left adrenal gland.
The tumor was suspected as a
pheochromocytoma because 24-hour urine
metanephrine and vanillymandellic acid levels
were found to be 5 mg (0-1 mg) and 9.2 mg (0-
8 mg).The patient's blood pressure was
220/130 mmHg and HR 105/min.

Which drug should be used to treat the
hypertension ?

1- Bisoprolol

2- Lisinopril

3- Phenoxybenzamine

4- Bendrofluazide

5- Indapamide

Answer & Comments

Answer: 3- Phenoxybenzamine

Physical examination showed that he had
diffuse lower extremity muscle tenderness,
crepitations in the lungs and a rash on the
trunks. Chest x-ray showed bilateral diffuse
pulmonary infiltrate.

Investigations showed:

urine protein 1+

urine sediment - many red blood cell and
granular casts

erythrocyte sedimentation rate (ESR) was 65
mm/hr

anti-nuclear antibody (ANA) - borderline
positive 1:40

anti-streptolysin O (ASO) antibody -< 1:40

c-ANCA - positive at a titer of 1:320, PR 3
positive

p - ANCA - negative

anti-double stranded DNA titer < less than 1:2.
What is the diagnosis?

1- Goodpasture's syndrome

2- Systemic lupus erythematosis

3- Microscopic polyangiitis

4- Wegener's granulomatosis

5- Sarcoidosis

In a patient with phaeochromocytoma,
irreversible alpha adrenoceptor blocker such
as phentolamine or phenoxybenzamine is
recommended as first line agents to treat
hypertension (Irreversible blockade is
important because a massive release of
catecholamines from the tumor may
overcome a reversible blockade).

[ Q: 2099 ] MRCPass - 2011 January

A 50 year old man presents with a
three month history of weight loss, diffuse
myalgia, epistaxis and hemoptysis.

He had a past medical history of hypertension,
and described episodes of haematuria.

Answer & Comments

Answer: 4- Wegener's granulomatosis

The diagnosis fits Wegener's best because of
the pulmonary and renal involvement.

In Wegener's, there is often pulmonary
haemorrhage, haemoptysis, infiltrates on the
CXR as well as cavitation. It is also associated
with rapidly progressive segmental necrotising
glomerulonephritis (75%) which may lead to
renal failure.

A diffuse, cytoplasmic pattern of staining
results from binding of ANCA to antigen
targets throughout the neutrophil cytoplasm,
the most common protein target being
proteinase 3 (PR3). PR3 is the most common

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antigen target of ANCA in patients with
Wegener's granulomatosis.

C-ANCA

cANCA - cytoplasmic staining

P-ANCA

p ANCA - perinuclear staining

[ Q: 2100 ] MRCPass - 2011 January

A 41 year old woman presented with
rectal bleeding. She has no past medical
history. Over the last two weeks, she noticed
rectal bleeding, and alternating constipation
and diarrhoea. Physical examination revealed
brown black pigmentation on the oral lips, the
buccal mucosa, about 1-3 mm in diameter.
She mentioned that these lesions were
longstanding. There were no palpable lymph
nodes palpable, no abdominal mass,
hepatosplenomegaly, or ascites.

Whot is the likely diagnosis?

1- Angiodysplasia

2- Colon carcinoma

3- Crohn's disease

4- Haemorrhoids

5- Ulcerative colitis

Answer & Comments

Answer: 2- Colon carcinoma

The pigmented oral lesions point tow ards a
diagnosis of Peutz-Jegher's syndrome, with
the cause of rectal bleeding being a rectal or
colonic carconima.

Peutz-Jeghers syndrome is an autosomal
dominant disease characterized by the
development of benign hamartomatous
polyps in the gastrointestinal tract and
hyperpigmented macules on the lips and oral
mucosa. There is a significant association with
increased risk of carcinoma. Cumulative
lifetime cancer risk begins to rise in middle
age. Gastrointestinal cancers and pancreatic
cancer are associated.

[ Q: 2101 ] MRCPass - 2011 January

A 45-year-old man was admitted
with acute-onset lower back and diarrhoea
occurring 7-8 times a day. Five weeks earlier,
he had a permanent pacemaker insertion for
symptomatic bradycardia. On examination he
was pyrexial. He had restricted lumbar spine
movement with pain at this site.

Investigations showed a normochromic
normocytic anaemia (haemoglobin 9.6 g/l),
and a white cell count of 18.0x109/1 (4.0-
11.0x109/1), urea 8.0 mmol/I (2.5-7.5 mmol/I),
creatinine of 160 |imol/l (60-120 |imol/l),
erythrocyte sedimentation rate (ESR) of 108
mm/h and CRP of 210 mg/I (<20 mg/I).

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What is the likely diagnosis?

1- Ankylosing spondylitis

2- Crohn's diseae

3- Clostridium difficile infection

4- Dysfunctional pacemaker

5- Staphylococcal discitis

Dapsone

Nitrofurantoin

Sulphonamides (co trimoxazole or septrin)
Quinolones (ciprofloxacin)

Primaquine (as an anti malarial drug)

Answer & Comments

Answer: 5- Staphylococcal discitis

This is a case of septic discitis (infection of the
spinal disc) due to staphylococcus, and it is
likely to be due to the recent pacemaker
insertion.

[ Q: 2102 ] MRCPass - 2011 January

A 30 year old patient has previously
presented with jaundice and diagnosed to
have G6PD deficiency. She seeks advice about
travelling to Africa because she wants to take
malaria prophylaxis.

Which drug should she avoid taking?

1- Quinine

2- Chloroquine

3- Artesunate

4- Primaquine

5- Doyxycycline

[ Q: 2103 ] MRCPass - 2011 January

A 53-year-old man was driving in a
car with his wife when they had an accident.
He suffered concussion during the car
accident. 6 months following this incident he
consults his GP mentioning that is tearful,
agitated, and unable to concentrate at work.
He has avoided visiting the site of the
accident, and also seems to deny the incident.
His wife's belongings are left untouched since
the day of the accident, and he still has visions
of his wife.

What is the most likely cause?

1- Anxiety disorder

2- Post traumatic stress disorder

3- Grief reaction

4- Post concussion

5- Psychotic depression

Answer & Comments

Answer: 3- Grief reaction

A grief reaction can last for up to 12 months,
but can vary within different cultures.

The average is probably around six months.
Symptoms of grief reaction are:

Answer & Comments

Answer: 4- Primaquine

A patient who is known to have G6PD
deficiency is prone to having haemolytic
jaundice due to drugs.

Drugs with risks of causing haemolysis in G6PD
deficiency are:

disbelief, shock, numbness and feelings of
unreality feelings of guilt

sadness and tearfulness

preoccupation with the deceased

disturbed sleep and appetite and,
occasionally, weight loss

seeing or hearing the voice of the deceased

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[ Q: 2104 ] MRCPass - 2011 January

A 30 year old patient has been on
warfarin for atrial fibrillation. His INR is 2.8.

Which one of the following is inhibited?

1- Factor V

2- Factor VII

3- Factor VIII

4- Platelet

5- Fibrinogen

Answer & Comments

Answer: 2- Factor VII

Warfarin is an antagonist of vitamin K, a
necessary element in the synthesis of clotting
factors II, VII, IX and X.

[ Q: 2105 ] MRCPass - 2011 January

A 60 year-old woman presents with
a history of acute leukemia of the Ml
phenotype.Initial treatment consisted of 2
cycles of induction therapy and 1 cycle of
high-dose cytarabine/mitoxantrone.

1 week later she became very unwell. She was
admitted to hospital and had a temperature of
39.5 C. She was treated with teicoplanin and
gentamicin intravenous, but 24 hours later she
worsened with high fevers.

What should be added to the treatment
regime?

1- Vancomycin

2- Amphotericin

3- Aciclovir

4- Flucloxacillin

5- Meropenem

Answer & Comments

Answer: 2- Amphotericin

Patients with AML who undergo
chemotherapy are at increased risk of fungal

infections, most commonly candidiasis and
aspergillosis.

This patient may have invasive fungal
infection. Amphotericin B therapy is the
treatment option for invasive candidiasis and
is also a treatment option for invasive
aspergillosis.

[ Q: 2106 ] MRCPass - 2011 January

A 40 year old African man had been
home for a holiday but this was 6 months ago.
He now presents with fever and intermittent
rigors. There has been no other travel history
and he has no past medical illnesses. The
patient gave the history of intermittent high
fever for the past 5 days accompanied by chills
and rigors, body-ache and vomiting.

What is the likely diagnosis?

1- Plasmodium malaria

2- Plasmodium falciparum

3- Plasmodium ovale

4- Dengue

5- Trypanosomiasis

Answer & Comments

Answer: 3- Plasmodium ovale

Due to the long period where the patient has
been well, the most likely cause is
plasmodium ovale or vivax infection.

The hypnozoites can develop into mature
schizonts and release merozoites into the
blood stream causing clinical symptoms of
malaria (relapsing malaria) even many months
after the primary infection.

Relapses can occur up to 5 years after
infection. Plasmodium vivax infection may
present similarly.

[ Q: 2107 ] MRCPass - 2011 January

A 62-year-old female is brought to
A&E by her family, who are concerned about

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her increasing confusion over the past 2 days.
There is a history of diarrhea in the preceding
few days. On examination she is found to be
pyrexial at 38oC. Breath sounds are clear and
there is mild tenderness in the lower
abdomen. There was no focal neurological
signs.

Blood tests reveal :

Hb 9.6 g/dl
WCC 12 x 10 9 /l
Platelets 65 x 10 9 /l
sodium 138 mmol/I
potassium 4.7 mmol/l
Urea 23.1 mmol/l
Creatinine 360 mmol/l
A blood film shows schistocytes.

What is the most likely organism?

1- Streptococcus faecalis

2- E coli

3- Staphylococcus aureus

4- Mycoplasma pneumoniae

5- Bacteroides

Answer & Comments

Answer: 2- E coli

presents with a history of shortness of breath,
anorexia, low -grade fever, and severe
anemia. Her investigation results showed:

Hb 4.5 g/dl

MCV 75 fl

WCC 16 x 1071 (60% blasts, 30% polymorphs)

platelets 90 x 1071

Bone marrow biopsy showed:

hypercellularity, altered myeloid to erythroid
(M:E) ratio, decreased megakaryocytosis,
mixed erythropoiesis.

There were blasts 65%, promyelocytes 61%,
myelocytes 02%, metamyelocytes 0.1%, band
cells 0.1%, polymorphs 19%, eosinophils 4%,
lymphocytes 35%.

There were occasional blasts with Auer rods,
many with azurophilic granules, suggestive of
acute myeloblastic leukaemia.

The patient was assessed for prognosis.

Which one of the following is a marker of a
good prognosis in acute promyelocytic
leukaemia?

1- Female sex

2- T(15:17)

3- Age of >60 years

4- Elevated LDH

The diagnosis here is Hemolytic uremic
syndrome (HUSIt is characterized by the triad
of microangiopathic hemolytic anemia,
thrombocytopenia, and acute renal failure.

Diarrhea and upper respiratory infection are
the most common precipitating factors. The
most common cause of HUS is a toxin
produced by Escherichia coli serotype
0157:H7.

Additional agents include Shigella, Salmonella,
Yersinia, and Campylobacter species.

[ Q: 2108 ] MRCPass - 2011 January
A 20 year old female patient

5- Philadelphia chromosome t(9:22) positive

Answer & Comments

Answer: 2- T (15:17)

Acute myeloid leukemia (AML), also known as
acute myelogenous leukemia, is the most
common acute leukemia affecting adults.

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marrow by leukemic myeloblasts. There are 8
subtypes.

of the child pugh criteria for liver failure) after
a paracetamol overdose.

Patients with AML can have high, normal, or
low WBC counts.

The single most important prognostic factor in
AML is cytogenetics, or the chromosomal
structure of the leukemic cell. Cytogenetic
karypotypes e.g. t(15;17), t(8;21) and

A number of other cytogenetic abnormalities
are known to associate with a poor prognosis:
5, -7, del(5q), Abnormal 3q, Complex
cytogenetics.

Age >60 years and elevated lactate
dehydrogenase level are also associated with
poorer outcomes in AML

[ Q: 2109 ] MRCPass - 2011 January

A 29 year old female took 40 tablets
of Paracetamol and was admitted to hospital.
She is seen the following day and needs
assessment of her medical condition.

Which of the following is the best investigation
to assess prognosis after 26 hours for a
paracetamol overdose?

1- Prothrombin time

2- AST

3- Paracetamol level

4- Urea and creatinine

5- Bilirubin

[ Q: 2110 ] MRCPass - 2011 January

* A 41 year old Caucasian female
presented with malaise, dysphagia and
sclerodactyly and Raynaud's phenomenon for
the last 3 months.

On physical examination she was afebrile and
had a supine blood pressure of 110/80mm Hg.
Sclerodactyly and telangiectasia were
observed in both hands. Blood tests revealed:

Hb 11.5 g/dl, MCV 85 fl

erythrocyte sedimentation rate of 80 mm/first
hour, antinuclear antibody (ANA) - strongly
positive antitopoisomerase I antibody
(formerly anti SCL-70 antibody) positive

normal C3 and C4

anti-DNA, anti-centromere, anti-RNP, anti-Ro
and La antibodies - negative

Chest x-ray showed bilateral basilar interstitial
infiltrates.

What is the diagnosis?

1- Hereditary haemorrhagic telangiectasia

2- Sjogren's syndrome

3- Wegener's granulomatosis

4- Oesophageal carcinoma

5- Limited systemis sclerosis

Answer & Comments

Answer: 5- Limited systemis sclerosis

The clues here for limited systemic sclerosis
(limited scleroderma) are dysphagia,
sclerodactyly and Raynaud's phenomenon.

Answer & Comments

Answer: 1- Prothrombin time

Although all of the tests may be abnormal, the
INR / prothrombin time measurement is the
most important in predicting prognosis (part

70% of patients initially present with
Raynaud's phenomenon; 95% eventually
develop it during the course of their disease.
Oesophageal dysmotility may cause reflux,
aspiration or dysphagia. Pulmonary fibrosis
and renal impairment are also associated.

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showed oesophageal varices which were not
bleeding.

Which one of the following drugs should the
patient be commenced on for prophylaxis of
bleeding?

1- Terlipressin

2- Propanolol

3- Lansoprazole

4- Mesalazine

[ Q: 2111 ] MRCPass - 2011 January

A 40 year old lady has been
commenced on docetaxel as part of
chemotherapy for ovarian carcinoma.

What is its mechanism of action?

1- Pyrimidine analogue

2- Purine analogue

3- Inhibition of thymidylate synthase

4- Binds and inhibits microtubules

5- Prednisolone

Answer & Comments

Answer: 2- Propanolol

For oesophageal varices, the non-selective a-
blockers (e.g., propranolol) and nitrates (e.g.
isosorbide mononitrate) have a role in
prophylaxis of bleeding. Terlipressin
(vasopressin analogue) is used in acute
bleeding as it is vasoactive.

5- Anthracycline intercalating DNA

Answer & Comments

Answer: 4- Binds and inhibits microtubules

Docetaxel is a clinically well established anti
mitotic chemotherapy drug used mainly for
the treatment of breast, ovarian, and non¬
small cell lung cancer.

Docetaxel binds to microtubules reversibly
with high affinity with the end result of
reducing mitotic division of cells.

[ Q: 2112 ] MRCPass - 2011 January

A 50-year-old man presented to the
emergency department with complaints of
fatigue, nausea and vomiting for several
months. He had a 20 pack-year smoking
history and alcohol intake consisted of a 20
units a day. On examination, he was jaundiced
and had palpable hepatomegaly. He was
organised to have upper Gl endoscopy, which

^ [ Q: 2113 ] MRCPass - 2011 January

f| -

# A 60-year-old woman is investigated
for weight loss, fatigue and anaemia. These
symptoms have been present for 1 year. She
has a history of hypertension and transient
ischaemic attack 2 years ago. Clinical
examination reveals splenomegaly palpable 5
cm below the costal margin. A full blood count
is reported as follows:

Hb 9.8 g/dl

Platelets 380 x 10 9 /l

WCC 120 x 10 9 /l

Blood film. Demonstrates left shift with
predominating myelocytes. Low percentage of
blast cells

What is the likely diagnosis?

1- Chronic myeloid leukaemia

2- Acute lymphoblastic leukaemia

3- Polycythaemic rubra vera

4- Waldenstrom's macroglobulinaemia

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5- Myelodysplasia

Answer & Comments

Answer: 1- Chronic myeloid leukaemia

The diagnosis here is chronic myeloid
leukaemia, which accounts for 20% of all
leukaemias.

It is one of the forms of myeloproliferative
leukaemias. It occurs mainly in middle aged
and elderly people and is characterised by
marked leucocytosis. CML is often suspected
when the blood count shows increased
granulocytes of all types, typically including
mature myeloid cells. A left shift (presence of
immature cells) myeloid series is present . In
95% of patients, there is the presence of the
chromosomal translocation, the Philadelphia
chromosome.

[ Q: 2114 ] MRCPass - 2011 January

A 85 year old man was hospitalised
after having found on the floor at home. He
had a history of ischaemic heart disease,
diabetes and previous surgery for prostate
carcinoma. Initial investigations suggested
that he had a urinary tract infection. During
the admission, he suddenly became very
agitated at night, and was lashing out at any
nursing staff who approached him to feed and
administer medications.

Which one of the following medications should
be used for sedation?

1- Propofol

2- Haloperidol

3- Olanzepine

4- Chlorpromazine

5- Temazepam

Answer & Comments

Answer: 2- Haloperidol

Pharmacologic management is necessary in
more severe cases of agitation in which
patients are a danger to themselves or others,
or are impeding medical evaluation and care.

The ideal agent for undifferentiated acutely
agitated geriatric patients would be effective
with a rapid onset of action and would be safe
with minimal side effects. Pharmacologic
options include the benzodiazepines and the
typical and atypical antipsychotics agents. The
typical antipsychotic Haloperidol is commonly
used for the treatment of acute agitation
because of its lower incidence of respiratory
depression, hypotension and anticholinergic
effects. Chlorpromazine and thioridazine are
also sedating antipsychotics, but they have
low potency. Olanzepine is an atypical
antipsychotic which may be used for chronic
agitation. Benzodiazepines may also be used
for acute agitation, lorazepam and midazolam
are more commonly used - However they are
associated with increased risk of falls, hypoxia
and respiratory depression.

[ Q: 2115 ] MRCPass - 2011 January

A 30-year-old man gradually noticed
that he had jaundice and dark urine since
being started on two medications by the GP.
He had no other symptoms; in particular there
was no itching, fever or bleeding, and he was
not previously taking any drugs. On
examination, he was anaemic and jaundiced.

His blood results are: Hb 5.5 g/dl, WCC 7 x
10 9 /l, platelets 200 x 10 9 /l. The blood film
showed polychromasia with nucleated red
cells and spherocytes; the reticulocyte count
was 9%. His serum bilirubin (47mmol/l),
aspartate transaminase (90iu/l) and lactate
dehydrogenase levels (5721iu/l) were raised.

Which one of the following tests will reveal
autoimmune haemolytic anaemia?

1- Cold agglutinins

2- Direct antiglobulin test

3- HAM's test

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4- Haptoglobins

5- G6PD levels

Answer & Comments

Answer: 2- Direct antiglobulin test

Antibody Autoimmune Hemolytic Anemia
(AIHA) is the most common of the
autoimmune hemolytic diseases.

The most common antibody involved in warm
antibody AIHA is IgG. Diagnosis is made by a
positive direct Coombs test.

The direct Coombs test is used to detect red
blood cells sensitized with IgG antibody, and
complement proteins. It detects antibodies
bound to the surface of red blood cells in vivo.

Corticosteroids and immunoglobulins are two
commonly used treatments for warm
antibody AIHA. Initial treatment consists of
prednisolone. If ineffective, splenectomy
should be considered.

Cold agglutinins are found in mycoplasma
infection and infectious mononucleosis.

[ Q: 2116 ] MRCPass - 2011 January

A 22 year old woman presented to
the Emergency Department because of
progressively severe unilateral knee pain of 24
hours duration. There was no preceding injury
or unusual physical activity was identified. She
did not have any significant past medical
history, but has been on a trip around Europe
over the last month. Plain radiographs of the
knee were unremarkable. On examination, the
left knee, right knee, right wrist and elbows
were erythematous and swollen. She did not
have a skin rash. A joint aspirate was done and
it showed no organisms but had increased
white cells, predominantly neutrophils. Her
ESR Is 60 mm/hr. A urethral swab was taken
and this did not show any cultures.

What is the most likely couse?

1- Lyme disease

2- Reactive arthritis

3- Septic arthritis

4- Psoriatic arthritis

5- Gonococcal arthritis

Answer & Comments

Answer: 2- Reactive arthritis

This young lady with no past medical history is
likely to have a reactive arthritis or septic
arthritis.

The arthralgia of gonococcal infection is most
often an asymmetric polyarthralgia. In this
patient However, the urethral cultures are
negative hence a reactive arthritis to a
different infection (e.g. Chlamydia, salmonella,
shigella, Campylobacter) which occurred
during the recent travel is more likely.

[ Q: 2117 ] MRCPass - 2011 January

A 26 year old woman was admitted
24 hours after taking 20 tablets of 50mg of
amitriptyline. She had no history of diabetes
or any other illnesses. On admission she had a
low conscious level and restless, the pulse was
130 beats per minute and her blood pressure
was 110/70mmHg. The heart sounds were
normal . The pupils were dilated but reactive
to light. The electrocardiogram (ECG) revealed
sinus tachycardia and the QRS duration was
wide.

Whot drug should be given?

1- Diazepam

2- Naloxone

3- Flumazenil

4- Sodium chloride

5- Sodium bicarbonate

Answer & Comments

Answer: 5- Sodium bicarbonate

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In amitryptiline overdoses, there are risks of
tachyarrhythmias which are best treated by
correction of hypoxia and acidosis.

Even in the absence of acidosis, sodium
bicarbonate should be given by intravenous
infusion to adults with arrhythmias or
clinically significant QRS prolongation on the
ECG.

[ Q: 2118 ] MRCPass - 2011 January

A 62 year old man presents with
dysphagia and dysphonia. Cranial nerve
examination revealed left-sided partial ptosis
with miosis, tongue deviation to the left, an
absent gag reflex, palatal palsy on the left, a
weak voice, and a wasted left
sternocleidomastoid muscle.

the cervical ganglia of the sympathetic trunk,
leading to Horner's syndrome.

[ Q: 2119 ] MRCPass - 2011 January

A 75-year old woman has presented
to the clinic for assessment. She has a past
medical history of palpitations and is
suspected to have congenital long QT
syndrome from evidence of her ECG findings.

Which one of these drugs should be avoided?

1- Amoxycillin

2- Thyroxine

3- Sertraline

4- Co-proxamol

5- Morphine

Which one of the following areas is
neurological damage most likely?

1- Pons

2- Lateral ventricles

3- Jugular foramen

4- Stylomastoid foramen

5- Cerebellopontine

Answer & Comments

Answer: 3- Jugular foramen

The jugular foramen syndrome is also known
as Vernet's syndrome.

The jugular foramen allows passage through
of IX, X and XI cranial nerves. In jugular
foramen syndrome, patients present with
difficulty in phonation and aspiration and
ipsilateral motor paralysis of the vocal cord,
soft palate (curtain sign), superior pharyngeal
constrictor, sternocleidomastoid, and
trapezius.

This syndrome may be caused by multiple
etiologies including trauma or tumor growth
for example, slow growing vascular tumours
such as glomus tumours. It can also involve

Answer & Comments

Answer: 3- Sertraline

Common drugs which cause long QT
syndrome are:

■ tricyclic antidepressants (e.g.
sertraline)

antiarrhythmics:
o quinidine
o disopyramide
o procainamide
o amiodarone
o sotalol

■ non-sedative antihistamine toxicity

o terfenadine

■ antimalarials

o halofantrine

■ antipsychotics

o notably haloperidol and
thioridazine
cisapride

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methadone

[ Q: 2120 ] MRCPass - 2011 January

A 66 year old man presented with a
sudden onset severe headache. There is a
history of hypertension and asthma. When he
was brought into hospital, he was found to
have a GCS score of 14. On examination, his
BP was 180/70 mmHg. He had a CT scan which
showed subarachnoid haemorrhage and he
was commenced on nimodipine and
monitored as an inpatient. On day 5, he
became more drow sy and confused. He did
not complain of a headache and had no focal
neurological signs. His GCS score dropped to
9 .

tolerance test and urinalysis were both
normal. During a water deprivation test
confirmed diabetes insipidus. Her serum
osmolality was 366 mOsm/kg, while her urine
osmolality was 156 mOsm/kg. She was given

l-desmino-8D-arginine-vasopressin (DDAVP),
and the results revealed suspected
nephrogenic diabetes insipidus. In this
condition, which one of these receptors is
defective?

1- Calcium

2- Potassium

3- Aquaporin 2

4- Erythropoietin

5- Cytosome

What is the most likely complication?

1- Subdural haematoma

2- Hydrocephalus

3- Cerebral infarct

4- Sagittal sinus thrombosis

5- Herniation of the brainstem

Answer & Comments

Answer: 3- Aquaporin 2

Aquaporins selectively conduct water
molecules in and out of the cell, while
preventing the passage of ions and other
solutes.

Answer & Comments

Answer: 2- Hydrocephalus

After the first 24 hours have passed,
rebleeding risk remains around 40% over the
subsequent four weeks.

The use of calcium channel blockers, thought
to be able to prevent the spasm of blood
vessels by preventing vasospasm. The oral
calcium channel blocker nimodipine improves
outcome if administered between the fourth
and tw enty-first day after the hemorrhage.
Hydrocephalus may complicate SAH in both
the short- and long term and may lead to a
drop in the GCS score.

There are several types of aquaporin
receptors, and aquaporin 2 absorbs water in
response to antidiuretic hormone.

Nephrogenic diabetes insipidus arises from
defective or absent receptor sites at the
cortical collecting duct segment of the
nephron or defective or absent aquaporin, the
protein that transports water at the collecting
duct (autosomal recessive, locus 12ql3).

[ Q: 2122 ] MRCPass - 2011 January

A patient with hemophilia A was
given DDAVP prior to dental extraction.

What is its mechanism of action in this
situation?

[ Q: 2121 ] MRCPass - 2011 January

A 17-year-old woman complained of
polydipsia, polyuria, and nocturia. Her glucose

1- Blocks anti diuretic hormone action

2- Release stored factor VIII

3- Increases ristocetin co factor activity

4- Promotes antithrombin activity

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5- Blocks the intrinsic pathway

Answer & Comments

Answer: 2- Release stored factor VIII

Desmopressin can be used to promote the
release of von willebrand factor and factor VIII
in patients with disorders such as von
Willebrand disease and mild hemophilia A
(factor VIII deficiency).

Although the mechanisms are not well
understood, desmopressin causes vw F and
factor VIII to be released from storage sites
such as vascular endothelium.

the scapula. He has a history of hypertension
and diabetes. He takes aspirin, gliclazide and
metformin. On examination, he has absent
pulses on the right arm and an irregularly
irregular heart beat. The blood pressure is 160
/ 100 mmHg. He had left sided arm and leg
weakness compared to the right.

What is the most likely diagnosis?

1- Thromboembolic CVA

2- Takayasu's arteritis

3- Aortic dissection

4- Left ventricular aneurysm

5- Ventricular septal defect

[ Q: 2123 ] MRCPass - 2011 January

Answer & Comments

• ! tj

A 25 year old man was admitted to

Answer: 3- Aortic dissection

the Psychiatric Ward with symptoms of
aggressiveness, inappropriate behaviour and
cyclothymia. On examination there was
evidence of psychomotor agitation, pressure
of speech and flight of ideas. A drug screen
was negative. A head CT was within normal
limits. A diagnosis of mania was made.

The patient has chest pain mimicking the
clinical history of myocardial infarction but has
two other features (absent pulses unilaterally
and hemiparesis) which could be
manifestations of occlusion of vascular supply
from the aorta.

What drug should be commenced?

1- Fluoxetine

2- Amitriptyline

3- Diazepam

4- Lithium

5- Clozapine

Answer & Comments

Answer: 4- Lithium

Lithium has traditionally been the first line of
treatment for mania since the 1970s and
evidence continues to show its effectiveness.

It can also be used as a mood stabiliser.

[ Q: 2124 ] MRCPass - 2011 January

A 66 year old man presents with
central chest pains radiating to the arm and

In aortic dissection, if the dissection flap
occludes the blood supply to the right arm
(subclavian artery) then an absent pulse may
occur and if the flap occludes the blood supply
to the brain (carotid arteries) a hemiparesis
can occur.

[ Q: 2125 ] MRCPass - 2011 January

A 62-year-old man is examined in the
cardiology clinic.

During cardiac examination it is noted that the
pulmonary component of the second heart
sound occurs before the aortic component.

Which one of the following is associated with
this finding?

1- Pulmonary stenosis

2- Left bundle branch block

3- Right bundle branch block

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4- Atrial septal defect

5- Deep inspiration

Answer & Comments

Answer: 2- Left bundle branch block

This patient has reversed splitting of the
second heart sound.

Left bundle branch block causes a reversed
split second heart sound as it results in a delay
in the aortic component.

[ Q: 2126 ] MRCPass - 2011 January

A 62 year old man presents with
worsening breathlessness, confusion and
headache. Since three months ago, he began
to have progressive exertional dyspnea,
aching in the legs, and pain in the left arm
(without chest discomfort) after 50 yards.
Upon further investigation, the results were
obtained:

IgA 2.8 (0.5-4.0) g/l
IgG 7 (5.0-13.0) g/l
IgM 24 (0.3-2.2) g/l
ESR 90 mm/hr

Which one of the following is likely to be
associated?

1- Hypercalcaemia

2- Hyperviscosity

3- Chronic renal failure

4- Diarrhoea

5- Demyelination

Answer & Comments

Answer: 2- Hyperviscosity

In this scenario, there is likely to be a
pulmonary embolus but the underlying
diagnosis is likely to be Waldenstrom's
macroglobulinemia due to the high IgM levels.

Waldenstrom's macroglobulinemia is a
malignant tumor of lymphocytic and
plasmacytic cells that secrete IgM. Patients
often present with hepatosplenomegaly and
lymphadenopathy. Most of the clinical
manifestations are due to the hyperviscosity
syndrome. Common presentations are:
fatigue, serum hyperviscosity - causing
mucosal and gastrointestinal bleeding, and
retinal haemorrhage); due to engorged vessels
and platelet dysfunction, purpura ,
hepatosplenomegaly and lymphadenopathy,
neurologic symptoms - alterations in
consciousness, peripheral neuropathy, visual
disturbance, nausea and vertigo.

[ Q: 2127 ] MRCPass - 2011 January

A 71 year old man presents with
shortness of breath on exertion. He has a
history of working in a dockyard. He has
smoked 15 cigarettes a day for the past 20
years. He had lost more than 7 kg in weight
over the past two months. On examination,
tar stained fingers and grade 3 finger clubbing
are noted. Auscultation and percussion of the
chest are suggestive of right sided pleural
effusion. A chest X ray confirms that he has a
right sided pleural effusion and also pleural
plaques. Mesothelioma is suspected.

What is the best way of confirming the
diagnosis?

1- MRI scan of the chest

2- Closed lung biopsy

3- Bronchoscopy

4- Fine needle aspiration

5- Video assisted thoracoscopy (VATS) biopsy

Answer & Comments

Answer 5- Video assisted thoracoscopy (VATS)
biopsy

Pleural mesothelioma usually begins as
discrete plaques and nodules that coalesce to
produce a sheetlike neoplasm.

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Subcutaneous malignant seeding of the
needle tract is a well-known complication of
percutaneous fine-needle aspiration biopsy
despite the fact that it may be less invasive.
Thus for sake of accuracy, a CT guided or
thoracoscopically guided biopsy (VATS) should
be performed if mesothelioma is suggested,
and results are diagnostic in 98% of cases.

[ Q: 2128 ] MRCPass - 2011 January

A 43 year old woman presents with
breathlessness and chest pains. She has a
history of pulmonary fibrosis associated with
connective tissue disease. She takes
prednisolone, n- acetylcysteine, salbutamol
and atrovent nebulisers. A lung function test
was organise to investigate the cause of
breathlessness and results are:

FVC (I) (% predicted) 2.28 (66%)

FEV1 (I) (% predicted) 2.04 (70%)

FEV1/FVC (%) 89

total lung capacity (TLC) = 2.9 L (70%)

TLCO mmol/kPa/min (% predicted) 8.5 (110)
KCO mmol/kPa/min/l (% predicted) 4.4 (150)
Whot is the diagnosis?

1- Pulmonary haemorrhage

2- Pulmonary embolism

3- Pleural effusion

4- Emphysema

5- Diaphragmatic weakness

Answer & Comments

Answer: 1- Pulmonary haemorrhage

[ Q: 2129 ] MRCPass - 2011 January

A 65-year-old was brought into
hospital for assessment of a progressive
memory loss and unsteadiness. A friend gives
a history that he has worsening symptoms of
difficulty walking, headaches and urinary
incontinence for the past ten months. On
examination, he walks with a wide based gait
and has an MMSE score of 18 / 30. An MRI
scan was organised, and this showed
significantly dilated ventricles with no
identifiable obstructive lesion.

What should be done?

1- CT angiogram

2- Lumbar puncture with CSF drainage

3- Trial of levodopa

4- Burr hole surgery

5- Intravenous methylprednisolone

Answer & Comments

Answer: 2- Lumbar puncture with CSF
drainage

The lung function shows a restrictive picture,
reduced FEV1 and FVC, which are consistent
with the underlying connective tissue disease.

However, as well as a slightly increased TLCO,
there is significantly increased KCO (transfer
factor) which suggests pulmonary
haemorrhage.

This patient has Normal pressure
hydrocephalus (NPH) is a clinical symptom
complex characterized by a triad of symptoms
which are: abnormal gait, urinary

incontinence, and dementia.

Is a form of communicating hydrocephalus in
which the intracranial pressure, as measured
by lumbar puncture, is normal or raised.

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Removal of CSF is a good diagnostic test as
symptoms often improve after a significant
volume of CSF is drained. A good response
suggests that ventriculo-peritoneal shunting
should be considered as definitive treatment.

[ Q: 2130 ] MRCPass - 2011 January

A 36-year-old white woman
presented with a 5 year history of plaques
over both shins. She had noted the gradual
development of fine blood vessels on her
shins. On examination, 10- to 15-cm, yellow ,
atrophic, centrally scarred plaques with
multiple telangiectases around the borders
were seen over both shins.

What should be checked?

1- Thyroid stimulating hormone (TSH)

2- Cortisol

3- Fasting blood glucose

4- Platelet count

5- Erythrocyte Sedimentation Rate

the scalp, face, or extremities) and erythema
nodosum (there are no telangiectasia).

[ Q: 2131 ] MRCPass - 2011 January

A 32-year-old woman presented
with a 2-day history of severe headache. She
was currently 30 weeks pregnant. She had a
history of hypertension, was a non-smoker
and was not diabetic.

On examination, she had a red right eye with
mild exophthalmos and clinically obvious
palsies of the right oculomotor, trochlear,
ophthalmic, and abducens nerves. There was
loss of pinprick sensation over the forehead.

What is the diagnosis?

1- Orbital cellulitis

2- Cavernous sinus thrombosis

3- Midbrain infarct

4- Posterior inferior cerebellar infarct

5- Grave's disease of the eye

Answer & Comments

Answer: 3- Fasting blood glucose

The diagnosis is likely to be Necrobiosis
lipoidica which is associated with diabetes,
hence the necessity to check the blood
glucose.

The lesions most commonly are located on the
shins but may occur on the face, trunk, and
arms.

They typically start as erythematous papules
over the pretibial areas and slow ly enlarge
and evolve to well-demarcated, atrophic,
shiny, yellow -brow n telangiectatic plaques.
They usually are multiple and bilateral. The
clinical appearance of necrobiosis lipoidica is
distinctive. The differential diagnostic
considerations include granuloma annulare
(typically found on the dorsa of hands, fingers,
and feet), sarcoidosis (red-brown papules on

Answer & Comments

Answer: 2- Cavernous sinus thrombosis

Cavernous sinus thrombosis is a very rare,
typically septic, thrombosis of the cavernous
sinus, usually caused by bacterial sinusitis.

Symptoms and signs include pain, proptosis,
ophthalmoplegia, vision loss, papilledema, and
fever.

There is often pain in the eye and forehead -
ophthalmic division of V may be affected,
exophthalmos and occasionally, papilloedema
are common and there could also be cranial
nerve palsies - III, IV, VI. Pregnancy is a risk
factor for venous sinus thrombosis, and
cavernous sinus thrombosis is included in this
category. Treatment is with antibiotics for any
underlying infection, and anticoagulation with
heparin (controversial).

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^ [ Q: 2132 ] MRCPass - 2011 January

t - -------

# A 36-year-old male, had a

splenectomy performed after medical

treatment for immune thrombocytopenic

purpura failed. At present, he is asymptomatic

and wants to know if any further action is

necessary for the future. He is concerned

about infections.

Which one of the following organisms is he
susceptible to?

1- E coli

2- Enterococcus

3- Klebsiella

4- Pneumococcus

5- Legionella

5- Thyroid hormone

Answer & Comments

Answer: 4- Dehydroepiandrosterone

Addison's disease can lead to a deficiency of
androgen hormones including testosterone,
dehydroepiandrosterone (DHEA), and DHEA
sulphate.

In women, androgens are produced in the
adrenal glands and the ovaries. In women,
adrenal androgens promote the development
of secondary sex characteristics such as
underarm and pubic hair.

These hormones may also be important for
women's libido (sex drive).

Answer & Comments

[ Q: 2134 ] MRCPass - 2011 January

Answer: 4- Pneumococcus

•I

A 21-year-old man without any

Although any encapsulated organism can
cause infection post splenectomy,
pneumococcus (Strep. Pneumoniae) is the
organism in more than 60% of cases.
According to guidelines published in the
Journal of Royal College of Physicians in 2002,
the standard of care for postsplenectomy
patients includes immunization with
pneumococcal vaccine (pneumovax), H.
influenza vaccine, and meningococcal vaccine
within 2 weeks of splenectomy.

[ Q: 2133 ] MRCPass - 2011 January

A 26 year old lady has been
diagnosed with addison's disease and recently
had developed secondary amenorrhoea as
well as loss of libido.

significant past history presented to his
physician with swelling of his hands and feet,
progressive dyspnoea and weight gain in
excess of 10 kg in the week prior to admission.
He also noted decreased frequency and
quantity of urine during this period. On
examination he had a blood pressure of
180/80 mmHg, heart rate of 90 and
respiratory rate of 16/min. There were no skin
lesions or lymphadenopathy, and all pulses
were palpable. There was 2+ pitting pedal in
the upper and lower limbs. He was also found
to be in acute renal impairment with a
creatinine of 250. Urine dipstick showed
proteinuria 4+. Blood tests results are as
below :

sodium 135 mmol/I
potassium 4.5 mmol/l

Which hormone deficiency is likely to lead to
the loss of libido?

1- Aldosterone

2- Cortisol

3- 17alpha OH progesterone

4- Dehydroepiandrosterone

urea 5 mmol/l
creatinine 100 |imol/l
ALT 32 (5-35) U/l
AST 25 (1-31) U/l
ALP 86 (20-120) U/l

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Albumin 22 (37-49) g/l

Total cholesterol 12 (< 5 ) mmol/L

The patient has been commenced on
prednisolone but remains hypertensive.

Whot should be commenced?

1- Rituximab

2- Azathioprine

3- Simvastatin

4- Ramipril

5- Penicillamine

Answer & Comments

Answer: 4- Ramipril

The patient has nephrotic syndrome as
indicated with oedema, hypoalbuminaemia
proteinuria and hypercholesterolaemia.

This is likely to be associated with a
glomerulophritis such as minimal change or

membranous nephropathy.

Prednisolone is the main treatment. However,
blood pressure control is also important with
an ACE inhibitor to reduce disease progression
and have an effect in reducing proteinuria in
the long term.

[ Q: 2135 ] MRCPass - 2011 January

A 55 year old man has a long history
of emphysema. He smoked 20 cigarettes a day
till the age of 45 but has discontinued now .
He had large bullae in the lung confirmed by
CT scans. He was referred for bullectomy.

Which one of the following is likely to occur
after surgery?

1- Increase in FEV1

2- Increase in intrathoracic gas volume

3- Decreased FEV1/FVC ratio

4- Decreased Vital capacity

5- Decreased DLCO

Answer & Comments

Answer: 1- Increase in FEV1

In patients with giant bullous emphysema,
bullectomy is the treatment of choice.

Indeed, patients have reported early
improvement of dyspnea, hypoxemia and
hypercapnia usually improve. In addition,
there is a rise in FEV1, FEV1/FVC ratio, and
diffusing capacity of the lung for carbon
monoxide (DLCO). The KCO (corrected
diffusion capacity) should remain the same.
The intrathoracic gas volume is decreased
after bullectomy.

[ Q: 2136 ] MRCPass - 2011 January

A 42-year-old has a history of dry
cough and fever for 2 months, and weight loss
and night sweats for 1 month.

He had a history of hypertension and was on
bendroflumethiazide. Several sputum samples
were sent and results revealed numerous
acid-fast bacilli. He was commenced on
quadruple TB therapy, two months later, the
patient complained of significant joint pains all
over the body.

Which one of the following drugs is likely to
couse this side effect?

1- Rifampicin

2- Isoniazid

3- Pyrazinamide

4- Ethambutol

5- Bendroflumethiazide

Answer & Comments

Answer: 3- Pyrazinamide

The most common (approximately 1%) side
effect of pyrazinamide is arthralgia.

Other side effects are hepatitis, vomiting and
sideroblastic anaemia.

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^ [Q: 2138] MRCPass-

2011 January

mft

A 55-year-old woman presents with

A 51-year-old man

has a sudden

weakness and pains in her limbs. She was
prescribed simvastatin for

hypercholesterolaemia 6 months ago. She has

recently been taking fruit juices as her
neighbour recommended it for health

reasons.

On admission, she had muscle weakness and a
raised serum creatine kinase of 8000 IU/1.
There was return of muscle enzymes to

normal shortly after stopping simvastatin.

Whot substance was likely to have interacted
with simvastatin to cause rhabdomyolysis?

1- Cranberry juice

attack of ataxia and weakness which required
admission. He has a history hypertension and
diabetes. He was a non-smoker and rarely
drank alcohol.

On examination, he had a left Horner's
syndrome with horizontal nystagmus, absent
left gag reflex. His speech was dysarthric.
There was also dysdiadochokinesia of the left
arm and leg and normal motor strength. Upon
sensory examination, there was decreased
pinprick sensation over the left side of the
face and entire right side of the body.

What is the most likely diagnosis?

2- Apple juice

3- Grapefruit juice

4- Blackcurrant juice

5- Orange juice

1- Multiple sclerosis

2- Brown sequard syndrome

3- Anterior spinal artery thrombosis

4- Pontine infarct

5- Posterior inferior cerebellar artery infarct

Answer & Comments

Answer: 3- Grapefruit juice

Simvastatin and atorvastatin are all
metabolized by CYP3A4 enzyme and have the
potential to interact with CYP3A4 substrates
and inhibitors.

Commonly quoted inhibitors include
erythromycin /clarithromycin, fluoxetine,
cyclosporine and grapefruit juice.

Consumption of grapefruit juice inhibits the
metabolism of statins-furanocoumarins in
grapefruit juice inhibit the cytochrome P450
enzyme CYP3A4, which is involved in the
metabolism of most statins and some other
medications (it had been thought that
flavonoids were responsible). This increases
the levels of the statin, increasing the risk of
dose-related adverse effects (including
myopathy/rhabdomyolysis).

Answer & Comments

Answer: 5- Posterior inferior cerebellar artery
infarct

Lateral Medullary Syndrome (Wallenberg's
syndrome) is of an infarct of the posterior
inferior cerebellar artery (or basilar artery).

The clinical features of lateral medullary
syndrome can be divided into those resulting
from brainstem or cerebellar dysfunction:

Cerebellar features:

■ ipsilateral limb ataxia

nystagmus to the side of the lesion

Brain stem features:

sudden onset of dizziness and
vomiting

dysphagia and dysarthria

ipsilateral Horner's syndrome

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ipsilateral facial sensory loss - pain
and temperature

ipsilateral pharyngeal and laryngeal
paralysis - cranial IX and X palsies
contralateral sensory loss - pain and

day history of urethral discharge. Mid stream
urine is negative. A swab was sent and was it
positive for chlamydia.

Which one of the following should be
prescribed?

1- Penicillin V

temperature of the limbs and trunk

^ [ Q: 2139 ] MRCPass - 2011 January

# A 45 year old patient has end stage
renal failure. He has haemodialysis 3 times a
week at the renal unit. He has become unwell
over 24 hours ago with erythematous line
insertion site. His blood pressure is 90/60
mmHg and he has a temperature of 39 C.
Dialysis line infection was suspected. Blood
cultures were taken but results are not
available yet.

2- Trimethoprim

3- Metronidazole

4- Doxycycline

5- Ciprofloxacin

Answer & Comments

Answer: 4- Doxycycline

The diagnosis is non gonococcal urethritis.

This is commonly due to Chlamydia.
Treatment of choice is doxycycline.

Which antibiotic should be commenced?

1- Amoxicillin

2- Gentamicin

3- Vancomycin

4- Linezolid

5- Teicoplanin

Answer & Comments

Answer: 3- Vancomycin

The likely organism is staphylococcus aureus
causing dialysis line infection.

In renal dialysis patients who are ill,
vancomycin should be started first as there is
a possibility of MRSA infection. If the blood
cultures subsequently grow staph aureus
which are sensitivie to methicillin then the
antibiotic can be changed to flucloxacillin to
complete a longer course of treatment eg. 2
weeks.

[ Q: 2140 ] MRCPass - 2011 January
A 19 year old female has a several

[ Q: 2141 ] MRCPass - 2011 January

A 70 year man presents with
complaints of visual changes. He is a type II
diabetic with a history of autonomic
neuropathy, hypertension and atrial
fibrillation. There is a history of sexual
dysfunction. Recently, he has been put on
sildenafil.

Which one of these is a recognised side effect?

1- Retinitis pigmentosa

2- Optic neuritis

3- Tunnel vision

4- Nystagmus

5- Bluish vision

Answer & Comments

Answer: 5- Bluish vision

Some sildenafil users have complained of
seeing everything tinted blue (cyanopsia).

Other most common side effects of sildenafil
use include headache, flushing, dyspepsia,
nasal congestion and impaired vision,

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including photophobia and blurred vision.
Digoxin causes yellow discolouration of vision
(xanthopsia).

2- Lisinopril

3- Amlodipine

4- Atenolol

[ Q: 2142 ] MRCPass - 2011 January

* A 36 year old lady has recently
presented with weight loss and anaemia.
Investigations confirmed that she had colon
carcinoma. Upon review , she said she that
both her parents had colon carcinoma. She
enquires about risks of other cancers.

Which one of the following is she most at risk
of developing?

1- Pancreatic carcinoma

2- Endometrial carcinoma

3- Small cell carcinoma of the lung

4- Squamous cell carcinoma of the lung

5- Breast carcinoma

Answer & Comments

Answer: 2- Endometrial carcinoma

5- Doxazosin

Answer & Comments

Answer: 3- Amlodipine

According to the British Hypertension Society
guidelines, Patients who are > 55 in age or
black should be on either a calcium channel
blocker (C) or thiazide diuretic (D).

Amlodipine is a calcium channel blocker hence
the best option here. Both thiazides and ACE
inhibitors can increase lithium concentration
levels.

[ Q: 2144 ] MRCPass - 2011 January

A 50 year old man presents with
severe crushing chest pains. His ECG showed
dominant R waves in VI and V2 leads. The T
waves were also tall.

The case scenario refers to the patient having
Hereditary nonpolyposis colorectal cancer
(HNPCC ) is an autosomal dominang condition.

Associated conditions apart from which has
colon cancer are cancers of the endometrium,
ovary, stomach, hepatobiliary tract and
urinary tract. Women with HNPCC have a 80%
lifetime risk of endometrial cancer. The
average age of diagnosis of endometrial
cancer is about 46 years.

[ Q: 2143 ] MRCPass - 2011 January

A 71 year old woman has been
referred for management of a blood pressure
of 190/100 mmHg. She has a history of bipolar
disorder and peripheral vascular disease. She
is currently on aspirin and lithium.

Which one of the following is the best
antihypertensive agent to commence?

1- Valsartan

Which artery is most likely to be occluded?

1- Right coronary artery

2- Septal branch of left anterior descending
artery

3- Circumflex artery

4- Posterior descending artery

5- Left main artery

Answer & Comments

Answer: 3- Circumflex artery

Posterior myocardial infarction usually results
from occlusion of the left circumflex coronary
artery but the anatomy can vary a little.

Occlusion of the right coronary artery may
also result in a posterior Ml.

The changes of posterior myocardial infarction
are seen indirectly in the anterior precordial
leads. Leads VI to V3 face the endocardial

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surface of the posterior wall of the left
ventricle. As these leads record from the
opposite side of the heart instead of directly
over the infarct, the changes of posterior
infarction are reversed in these leads. The R
waves increase in size, becoming broader and
dominant, and are associated with ST
depression and upright T waves.

[ Q: 2145 ] MRCPass - 2011 January

A 35-year old man was referred with
a two-month history of generalised weakness,
fever, and weight loss.

There was no other relevant past medical
history. Physical examination revealed a
moderately wasted young man with severe
pallor and pyrexia of 39°C. The spleen was
palpable 6 cm below the left costal margin.

Blood results showed:

Hb was 9 g/dl

haematocrit was 18%

white cell count 5.3 x 10 9 /l

platelet count was 89 x 10 9 /I

His reticulocyte count was <0.0001%.

There were some tear drop erythrocytes in his
blood film with 4 normoblasts per 100
leucocytes interspersed by myelocytes. The
bone marrow biopsy showed replacement of
normal haemopoietic elements by early
fibrosis.

What is the likely diagnosis?

1- Chronic myeloid leukaemia

2- Essential thrombocythaemia

3- Myelofibrosis

4- Multiple myeloma

5- Waldenstrom's macroglobulinaemia

Myelofibrosis is a chronic, progressive
myeloproliferative disease.

It is characterised by prominent bone marrow
stromal reaction including collagen fibrosis
and osteosclerosis.

Clinical features include lethargy,
constitutional symptoms, transfusion
dependent anaemia, splenomegaly, tear drop
poikilocytosis, and a leucoerythroblastic blood
film. A leucoerythroblastic picture on blood
film is commonly seen in conditions with
marrow infiltration. Immature cells
(myelocytes and normoblasts) are also seen
on the blood film.

[ Q: 2146 ] MRCPass - 2011 January

A 55-year-old woman presents for
evaluation of a chronic cough, productive of
very thick, yellow sputum that sometimes
becomes blood-tinged. She has experienced
recurrent episodes of fever associated with
pleuritic chest pain. Over the last 5 years, she
has developed shortness of breath with
exertion. A CT scan was performed and it
revealed that she had bronchiectasis. A recent
result for sputum culture sent by the GP
showed the presence of pseudomonas,
although sensitivities are not known.

What antibiotic should be commenced?

1- Amoxicillin

2- Clarithromycin

3- Cephradine

4- Ciprofloxacin

5- Vancomycin

Answer & Comments

Answer: 4- Ciprofloxacin

Answer & Comments

Answer: 3- Myelofibrosis

Bronchiectasis is an uncommon condition that
is characterized by irreversible dilation of the
bronchi.

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Chronic pulmonary infections and airw ay
inflammation cause bronchial damage through
destruction of the muscular and elastic layer
of the bronchial wall, leading to
bronchiectasis. Antimicrobial therapy should
target the following common pathogens
depending on the patient specific risk factors:
Haemophilus influenza, Pseudomonas
aeruginosa, Staphylococcus aureus, and
Streptococcus pneumoniae.

P. aeruginosa usually becomes a chronic
infection and is rarely eradicated, despite the
use of intravenous antibiotic therapy.
Fluoroquinolones such as ciprofloxacin or
levofloxacin are reasonable outpatient
antibiotics in patients with severe symptoms
for 7-14 days. Other antibiotics which are
effective are gentamicin, tobramycin and
ceftazidime.

[ Q: 2147 ] MRCPass - 2011 January

A 25 year old lady returned from
Indonesia 2 weeks ago and now feels unwell.
Whilst she was there she was bitten by
mosquitos. She is lethargic, has significant
myalgia and complained of fevers. Her
temperature was 39.6 C and her blood
pressure was 85 / 60 mmHg . There was a
generalized petechial rash in the lower part of
the body. Blood tests showed raised
inflammatory markers and a malarial film was
negative on admission.

What treatment should be commenced?

1- Morphine

2- Intravenous quinine

3- Intravenous fluids

4- Intravenous ceftriaxone

5- Intravenous prednisolone

Answer & Comments

Answer: 3- Intravenous fluids

This patient is likely to have dengue fever, as
she has just returned from South East Asia.

She also exhibits features of a purpuric rash,
myalgia, fevers (and also frequently a
thrombocytopenia). Treatment is supportive,
as the disease is self limiting.

[ Q: 2148 ] MRCPass - 2011 January

A 20 year old man was referred for
pink discolouration of his urine to the hospital.
He had no previous relevant medical history. 3
days ago he complained of a sore throat and
was given a course of amoxicillin and
ibuprofen by the GP but those symptoms have
resolved now . On examination, he looked
well. His blood pressure was 120/70 mmHg,
temperature 36 C. There were normal
abdominal examination and he had no
palpable organomegaly. Urine dipstick showed
blood ++, Protein +, nitrites negative.

Whot is the most likely diagnosis?

1- Crescentic glomerulonephritis

2- Wegener's granulomatosis

3- IgA nephropathy

4- Post streptococcal glomerulonephritis

5- Goodpasture's syndrome

Answer & Comments

Answer: 3- IgA nephropathy

IgA nephropathy is the most common
glomerulonephritis and is characterized by
deposition of the IgA antibody in the
glomerulus.

The classic presentation (in 40-50% of the
cases) is episodic frank hematuria which
usually starts within a day or two of a non¬
specific upper respiratory tract infection. The
common differential is post-streptococcal
glomerulonephritis which typically occurs
weeks after initial infection. The gross
hematuria resolves after a few days, though
microscopic hematuria may persist. Renal
function usually remains normal. Mild
proteinuria can also be associated.

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[ Q: 2149 ] MRCPass - 2011 January

A 50 year old man with heartburn
was referred by the GP for endoscopy. He has
had the endoscopy done, it showed Barrett's
oesophagus. A histology specimen showed
that there was no H pylori infection and
dysplastic features.

What should be done next?

1- No medication required

2- Start triple therapy

3- Start PPI and discharge

4- Start PPI and follow up with repeat
endoscopy in 2 years

5- Start PPI and repeat endoscopy in 8 weeks

Answer & Comments

Answer: 5- Start PPI and repeat endoscopy in
8 weeks

Barrett's oesophagus (columnar-lined
oesophagus[CLO] ) is an oesophagus in which
any portion of the normal squamous lining has
been replaced by a metaplastic columnar
epithelium which is visible macroscopically.

has a temperature of 38.5C. A lumbar
puncture was performed. Results showed:

CSF pressure: 12 cm

glucose - 3.7 mmol/l

protein < 0.55 g/l

white cells 290 (95% lymphocytes)

An MRI scan showed high signal in the
temporal lobes including hippocampal
formations and parahippogampal gyrae and
right inferior frontal gyrus.

What is the likely diagnosis?

1- Pneumococcal meningitis

2- Guillain Barre syndrome

3- TB meningitis

4- Poliomyelitis

5- Herpes simplex virus encephalitis

Answer & Comments

Answer: 5- Herpes simplex virus encephalitis

In Herpes simplex virus (HSV) encephalitis, a
presentation with fevers, confusion or a
change in personality is common.

CLO represents the extreme end of the
pathophysiological spectrum of gastro-
oesophageal reflux disease.

If the endoscopy shows no dysplastic features,
surveillance should be discussed with the
patient and it is recommended that it should
be performed every 2 years.

The CSF white cell count is elevated with
lymphocytosis. The majority of cases of herpes
encephalitis are caused by herpes simplex
virus-1 (HSV-1) . The MRI typically shows high
signal changes in the T2 weighted images in
the temporal lobe areas, in HSV encephalitis.
Treatment is with iv acyclovir.

If there were features of dysplasia, then the
patient should be managed firstly by extensive
re-biopsy after intensive acid suppression for
8-12 weeks. If the features of dysplasia
persist, surveillance should be six monthly and
if the features progress surgery may be
recommended.

[ Q: 2150 ] MRCPass - 2011 January

A 62 year old woman presents with
confusion, headache and neck stiffness. She

^ [ Q: 2151 ] MRCPass - 2011 January

* A 45-year-old woman presents with
weight gain and recurrent 'dizzy' episodes.
Over the past four months she has gained 10
kg. The episodes occur on an almost daily
basis and are characterised by blurred vision,
sweating and headaches. Her GP checked a
blood sugar during one of these episodes
which was record as being 2.0 mmol/l.

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What is the most useful test to confirm the
diagnosis?

1- Insulin tolerance test

2- Oral glucose tolerance test

3- 72 hour fast with Insulin + C-peptide levels

4- Sulphonylurea level

5- Thyroid function

2- Asymmetrical bradykinesia

3- Intention tremor

4- Ataxic gait

5- Sensory ataxia

Answer & Comments

Answer: 2- Asymmetrical bradykinesia

Answer & Comments

Answer: 3- 72 hour fast with Insulin + C-
peptide levels

A 72-hour fast, usually supervised in a hospital
setting, measuring any hypoglycaemia(glucose
<2.5 mmol/l), insulin and C peptide level
(which are elevated during one of these
episodes) will confirm the diagnosis of a
possible insulinoma (pancreatic insulin
secreting tumour as suggested in the clinical
history).

Idiopathic Parkinson's disease is characterised
by tremor, rigidity and bradykinesia (which is
typically asymmetrical).

There are also features of postural instability,
a mask like face and a shuffling gait.

[ Q: 2153 ] MRCPass - 2011 January
A 70 year old lady presents with

visual problems.

On examination, she had a homonymous
superior left homonymous quadrantinopia.

The C peptide levels are useful as proinsulin is
broken down to insulin and C peptide.

Whot is the likely site of lesion?

1- Frontal lobe

If present, then the patient is unlikely to be
injecting insulin exogenously (which is among
the possibilities in patients with unexplained
hypoglycaemic episodes).

[ Q: 2152 ] MRCPass - 2011 January

A 60 year old woman presents with a
four-year history of increasing stiffness and
immobility which have led to multiple falls.
She had had some difficulty in fine finger
movement. Her Blood pressure was 130/90
mmHg lying and 135/95 mmHg standing.
Examination showed a mask like facies,
bradykinesia, nuchal and limb rigidity. She had
an asymmetrical tremor in her hands and
cogw heel rigidity in the arms. There was also
short-term memory loss.

Which one of the following features most
likely suggests Parkinson's disease?

1- Flaccidity

2- Parietal lobe

3- Occipital lobe

4- Temporal lobe

5- Cerebellum

Answer & Comments

Answer: 4- Temporal lobe

Inferior quadrantinopia is a sign of a parietal
lobe lesion, whilst a superior quadrantinopia is
a sign of a temporal lobe lesion.

[ Q: 2154 ] MRCPass - 2011 January

A 35 year old man was found to have
a heart murmur on a routine check up and his
GP refers him to the general medical clinic.

He has a past medical history of asthma. On
examination, blood pressure was 110/ 60 mm
Hg. The JVP is not elevated. Cardiac
auscultation evidenced a grade III pan systolic

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murmur at both the cardiac apex and left
sternal border. A thrill was palpable at the left
parasternal area.

Whot is the likely diagnosis?

1- Mitral regurgitation

2- Aortic stenosis

3- Tricuspid regurgitation

4- Atrial septal defect

5- Ventricular septal defect

Answer & Comments

Answer: 5- Ventricular septal defect

A small VSD could present with few symptoms
until a heart murmur is picked up.

Answer & Comments

Answer: 2- Medullary thyroid carcinoma

This lady has hypertension and thyroid
nodules.

The symptoms and hypertension suggest an
underlying phaeochromocytoma. The thyroid
nodules with normal thyroid function tests is
consistent with multiple endocrine neoplasia
(MEN), in this case type 2 fits where the
patient may have medullary thyroid
carcinoma.

MEN 1 associations are: pituitary tumour,
parathyroid hyperplasia/tumour, pancreatic
tumours (most commonly gastrinoma /
insulinoma).

A palpable thrill and pan systolic mumur in the
left parasternal region is typical.

[ Q: 2155 ] MRCPass - 2011 January

A 25 year old woman presents with
irritability, diarrhoea, sw eatiness and
palpitations. She has no past medical history
and is currently not taking medications. She
has a family history of her maternal uncle
having primary hyperparathyroidism at the
age of 35 yrs and his son also had a similar
diagnosis. On examination, her BP is 190 / 110
mmHg. She had palpable thyroid nodules. Her
blood results are:

sodium 135 mmol/I, potassium 4.3 mmol/l,
urea 5 mmol/l, creatinine 100 pmol/l,calcium
3.2 (2.25-2.7) mmol/l, phosphate 0.7 (0.8-8)
pmol/l. free T4 18 (10-24) pmol/l, TSH 3.2
(0.3-4) mll/l.

Which one of the following thyroid conditions
is associated?

1- Papillary thyroid carcinoma

2- Medullary thyroid carcinoma

3- Hashimoto's disease

4- Grave's disease

5- Iodine deficiency

MEN 2a is associated with medullary thyroid
carcinoma (MTC), parathyroid tumours (10-
20%) and pheochromocytoma (20-50%).

MEN 2b is associated with presentation of
medullary thyroid carcinoma, parathyroid
tumours and pheochromocytoma +
ganglioneuromatosis (pathognomonic).

[ Q: 2156 ] MRCPass - 2011 January

A 30 year old lady has severe
bleeding gums for 6 months and is referred to
a haematologist who organised the following
tests with these results:

Hemoglobin 12 g/dl (10.5-13.5)
Hematocrit 37% (33.0-39.0)

WBC 7.9 x 10 9 /L (6.0-17.5)
Platelets 330 x 10 9 /L (156-369)

PT 11.3 s (10.0-12.8)

APTT 49s (28.0-38.0)

FACTOR VIII 0.15 U/ml (0.60-1.50)
FACTOR IX 0.82 U/ml (0.60-1.50)
THROMBIN TIME 18s (16.0-22.0)
RCOF <0.10 U/ml (0.50-1.50)

What is the diagnosis?

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1- Hemophilia A

2- Hemophilia B

3- Von Willebrand's disease

4- DDAVP deficiency

5- Factor V leiden deficiency

Answer & Comments

Answer: 3- Von Willebrand's disease

Von Willebrand's disease is caused by
congenital deficiency (or dysfunction) of vWF,
a protein cofactor essential for normal platelet
adhesion and for the transport of Factor VIII.

Bleeding time is prolonged, platelets show
reduced adhesion and levels of Factor VIII are
low . Inheritance is usually autosomal
dominant, but in the severe forms it may be
recessive.

The disease is phenotypically classified into
three broad categories:

Type 1 (partial quantitative deficiency, most
common type)

Type 2 (qualitative defect)

which was bloody. Ischaemic colitis was
diagnosed following a surgical review .

Where is the most commmon site for the
condition?

1- Hepatic flexure

2- Splenic flexure

3- Caecum

4- Sigmoid

5- Rectum

Answer & Comments

Answer: 2- Splenic flexure

The colon receives blood from both the
superior and inferior mesenteric arteries.

The blood supply from these two major
arteries overlap, with abundant collateral
circulation. However, there are weak points,
or "watershed" areas, at the borders of the
territory supplied by each of these arteries,
such as the splenic flexure and the transverse
portion of the colon. These watershed areas
are most vulnerable to ischemia, thus leading
to ischaemic colitis.

Type 3 (total deficiency)

Useful tests for diagnosing von Willebrand's
Disease are:

increased template bleeding time

[ Q: 2158 ] MRCPass - 2011 January

Which one of the hormones listed
below is under a state of continuous
inhibition?

low factor VIII level (vWF protect FVIII from
degradation)

reduced levels of vWF: Antigen ristocetin
cofactor activity RCOF - ristocetin fails to
induce platelet aggregation(because of lack of
vWF:R - a cofactor for ristocetin)

1- Prolactin

2- Growth hormone

3- Adrenocorticotrophic hormone (ACTH)

4- Thyroid stimulating hormone (TSH)

5- Anti diuretic hormone (ADH)

[ Q: 2157 ] MRCPass - 2011 January

A 72-year-old male presents to the
emergency department with sudden-onset,
diffuse abdominal pain that began 18 hours
ago. He has not been vomiting, but he has had
several episodes of diarrhoea, the last of

Answer & Comments

Answer: 1- Prolactin

Prolactin release from the pituitary is inhibited
(under negative control) by dopamine (from
hypothalamus). Dopamine produced by
neurons in the hypothalamus is secreted into

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the hypothalamo-hypophysial blood vessels
which supply the pituitary gland.

The lactotrope cells that produce prolactin
and in the absence of dopamine, would
secrete prolactin continuously.

[ Q: 2159 ] MRCPass - 2011 January

A 48 year old man is known to have
alcoholic liver cirrhosis. He drinks 60 units of
alcohol per week. He presents unwell and
complains of abdominal distension and
abdominal pain. Temperature is 38 C and
blood pressure is 96/50 mmHg. Abdominal
palpation reveals hepatomegaly and ascites
with shifting dullness.

What should be done next?

1- Albumin infusion

2- Ascitic fluid cytology

3- Ascitic fluid microscopy

4- Liver biopsy

5- ultrasound of the abdomen

Answer & Comments

Answer: 3- Ascitic fluid microscopy

There is a high chance of spontaneous
bacterial peritonitis (SBP) in this patient with
cirrhotic liver disease.

When analysis of ascitic fluid reveals a white
blood cell count of more than 250 cells/cc,
SBP is likely. Cefotaxime should be
commenced after a tap is done and blood
cultures are sent.

^ [ Q: 2160 ] MRCPass - 2011 January

# A 30-year-old man presented with a
pruritic rash, which he has had for 3 months.
The rash is present on the arm, elbows,
buttocks and thigh. He has no significant past
medical history but mentioned that he had
frequent episodes of loose stool which he had
accepted was normal for him. The GP

prescribed betnovate creams which have not
helped the lesions. On examination, he was
noted to have many papular, vesicular lesions,
of average 0.5 cm each.

Whot is the likely diagnosis?

1- Erythema marginatum

2- Erythema multiforme

3- Guttate psoriasis

4- Dermatitis herpetiformis

5- Pityriasis versicolor

Answer & Comments

Answer: 4- Dermatitis herpetiformis

Dermatitis herpetiformis is characterized by
intensely itchy chronic papulovesicular
eruptions, usually distributed symmetrically
on extensor surfaces (buttocks, back of neck,
scalp, elbows, knees, back). Dermatitis
herpetiformis

symptoms typically first appear in the early
years of adulthood between 20 and 30 years
of age. There is a strong association with
gluten intolerance (celiac disease)

Diagnosis is confirmed by a skin biopsy which
reveals IgA deposits in the dermal papillae,
revealed by direct immunofluorescence.
Dapsone is an effective treatment for most
patients. A gluten free diet also often leads to
symptom improvement.

[ Q: 2161 ] MRCPass - 2011 January

A 32 year old man complained of
severe pain in the feet which are burning and
painful typically at night. He has type 1
diabetes and is on lantus and novorapid
insulin. He has poor glycaemic control and a
HbAlc of 9.5 %. He took diclofenac but the
pain was not relieved completely.

What is the best treatment for this man?

1- Physiotherapy

2- Gabapentin

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3- Morphine

4- Fluoxetine

5- Bed rest

Answer & Comments

Answer: 2- Gabapentin

This patient has peripheral neuropathy
causing pain.

1- Hydroxyurea

2- Aspirin

3- Intravenous immunoglobulin

4- Abxicimab

5- Prednisolone

Answer & Comments

Answer: 1- Hydroxyurea

Although they can provide real relief, NSAIDs
have a "ceiling effect" - that is, there's a limit
to how much pain they can control.

Neuropathic agensts such as tricyclic
antidepressants ( nortriptyline or amitriptyline
) anticonvulsant drugs, such as gabapentin,
also may be prescribed for chronic pain. They
may help by blocking pain messages to the
brain or by enhancing the production of
endorphins, body's natural painkillers.

[ Q: 2162 ] MRCPass - 2011 January

A 65-year-old white man was
referred following several significant episodes
of epistaxis. Physical examination
demonstrated no lymphadenopathy, no
bruises, and no purpura. His liver was
palpated 1 cm below the right costal margin.
The spleen was not palpable.

Blood tests results showed:

hemoglobin level of 9 g/dL

mean corpuscular volume, 84 x 10-15 L (80-
96)

white blood cell count, 10 x 10 3 /|il_
platelets, 900 x 10 3 /|iL.

Bone marrow biopsy showed marked
megakaryocytic hyperplasia, morphologically
abnormal megakaryocytes with nuclear
pleomorphism, and clustering of
megakaryocytes

A diagnosis of essential thrombocythemia was
suspected.

What drug should be commenced?

Essential thrombocythemia is a chronic
myeloproliferative disorder characterized by
sustained thrombocytosis in the blood (
peripheral blood platelet count greater than
600 ?~ 109/L) and increased numbers of large,
mature megakaryocytes in the bone marrow .

In some cases this disorder may be
progressive, and rarely may evolve into acute
myeloid leukemia or myelofibrosis. Not all
patients will require treatment at
presentation. In those who are at increased
risk of thrombosis or bleeding (older age, prior
history of bleeding or thrombosis, or very high
platelet count), reduction of the platelet count
to the normal range can be achieved using
hydroxyurea (also known as

hydroxycarbamide), interferon-f? or
anagrelide (phosphodiesterase inhibitor). Low
-dose aspirin is also widely used to reduce the
risk of thrombosis.

[ Q: 2163 ] MRCPass - 2011 January

A 26 year old lady presents with
abdominal pains and lethargy. She has a
history of diabetes and was on insulin.

Clinical examination was unremarkable and
she had an abdominal X ray which showed the
presence of renal calculi.

Investigations revealed the following:

arterial blood pH 7.30 (7.38-7.44)

serum bicarbonate 12.6 mmol/L (21-28
mmol/L)

sodium 146 (136-145 mmol/L)

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potassium 2.8 (3.5-5mmol/L)
chloride 122 (98-106mmol/L)

Anion gap was 15 (normal 7-16 mmol/L)
Urine pH of 6.5 (normal range 5-9)

Whot is the likely diagnosis?

1- Multiple myeloma

2- Renal tubular acidosis type 1

3- Nephrotic syndrome

4- Homocystinuria

5- Porphyria

Answer & Comments

Answer: 2- Renal tubular acidosis type 1

The diagnosis of Type 1 RTA is based on the
findings of metabolic acidosis, low
bicarbonate, -hypokalemia, a normal anion
gap (the anion gap here is Na + K - Cl - HC03 =
14.6 which is normal) and relatively alkaline
urine despite the acidosis.

Type 1 RTA can be familial with autosomal
dominant as the most common mode of
inheritance.

Typical features of type 1 RTA are
osteomalacia and nephrocalcinosis.
Associated causes are Sjogren's syndrome,
SLE, rheumatoid arthritis, renal
transplantation and sickle cell anaemia.

[ Q: 2164 ] MRCPass - 2011 January

A 35 year old man presented with
severe retrosternal chest pain. He has history
of frequent cocaine use. His blood pressure in
200/110 mmHg and his ECG shows anterior

wall myocardial infarction with ST elevation in
leads VI to V4. He has been given Aspirin by
the ambulance crew.

Whot is the likely couse of the presentation?

1- Atherosclerosis

2- Vasculitis

3- Coronary vasospasm

4- Cardiac arrhythmia

5- Vessel thrombosis

Answer & Comments

Answer: 3- Coronary vasospasm

This man has cocaine induced coronary
vasospasm.

Whilst this is frequently transient and can be
relieved by vasodilators, it can lead to an ST
elevation myocardial infarction. Thrombolytics
and anticoagulation will be of minimal effect
as it is not a thrombotic event like most other
myocardial infarction cases.

[ Q: 2165 ] MRCPass - 2011 January

A 32 year old woman has presented
with symptoms of haemoptysis for 6 months.
Urine dipstick showed blood ++ and she was
noted to have renal impairment with a
creatinine of 160 umol/l. A Chest XR showed
upper lobe infiltrates. A renal biopsy was
performed, and this showed crescentic
accumulation of cells, deposition of IgG in
glomerular basement membrane and
extracellular material in the urinary space of a
glomeruli.

Which one of the following tests is likely to be
positive?

1- Anti centromere antibody

2- P ANCA

3- C ANCA

4- Anti smooth muscle antibody

5- Anti GBM antibody

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Answer & Comments

Answer: 5- Anti GBM antibody

A patient with pulmonary haemorrhage and
crescentic glomerulonephritis (anti GBM
positive) or microscopic polyangitis (p ANCA
positive and anti myeloperoxidase antibody
positive).

In Goodpasture's syndrome, the renal biopsy
typically shows linear IgG deposition along the
basement membrane. If the patient had a
wheeze and eosinophilia, then the description
fits a patient with Churg Strauss syndrome
(also anti myeloperoxidase antibody positive).

[ Q: 2166 ] MRCPass - 2011 January

A 52-year-old man presented with
an insidious 12-month history of a sensation
of food getting stuck in his throat, and
regurgitation of small amounts of previously
eaten food, some hours after a meal. He also
mentioned that his family mentioned
significant halitosis. He said he had lost 1
stone over the last year. On examination, he
had a normal oral cavity and sw allowing
ability, but halitosis was noted.

What is the likely diagnosis?

underlying mucosa through this weakness in
the muscles.

The most common clinical findings of a
pharyngeal pouch include dysphagia, or the
feeling of a lump in the throat.

Regurgitation of food and mucus a few hours
after eating may occur, in addition to halitosis
as a result of food being trapped in the pouch.

[ Q: 2167 ] MRCPass - 2011 January

A 61 year old man presents with
bradykinesia and mask like facies. He was
found to have cogw heeling and bradykinesia.
His gait is shuffling in nature.

Which one of the following drugs is most likely
to help the bradykinesia?

1- Amantadine

2- Benzhexol

3- Bromocriptine

4- Levodopa

5- Selegiline

Answer & Comments

Answer: 4- Levodopa

1- Gastroesophageal reflux

2- Pharyngeal pouch

3- Oesophageal adenocarcinoma

4- Hiatus hernia

5- Gastric ulcer

Answer & Comments

Answer: 2- Pharyngeal pouch

A pharyngeal pouch is a pulsion diverticulum
of the pharyngeal mucosa through a
weakening between the cricopharyngeus and
thyropharyngeus muscles at the top of the
oesophagus.

The pressure generated by swallowing can
over time result in an out-pouching of the

The primary pathology in Parkinson's disease
is loss of dopaminergic action in the substantia
nigra, leading to rigidity, bradykinesia and
tremors.

Bradykinesia results from a failure of basal
ganglia output to reinforce the cortical
mechanisms that prepare and execute the
commands to move. The first line treatment is
with L-dopa which is the metabolic precursor
of L-dopa. Benzhexol is an anticholinergic drug
(used to alleviate tremors in parkinson's
disease), and is not effective against
bradykinesia.

Dopamine agonists (bromocriptine) and MAO
inhibitors (selegiline) are used as adjuncts to
patients who have motor fluctuations on L-
dopa.

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[ Q: 2168 ] MRCPass - 2011 January

A 40 year old lady has had a renal
transplant 4 years ago. She has end stage
renal failure due to diabetes and
hypertension. She is on the following
medications: tacrolimus , azathioprine,

prednisolone , lansoprazole and insulin
novomix . Her baseline creatinine has been
100 for the last two years. She came to clinic
for blood tests which show these results:

Hb 11.0 g/dl, WCC 12 x 10 9 /l platelets 250 x

10 9 /l

sodium 136 mmol/I, potassium 6.6 mmol/I

urea 6 mmol/I

creatinine 105 |imol/l

Whot is the likely cause of hyperkalaemia?

1- Tacrolimus

2- Azathioprine

3- Prednisolone

4- Lansoprazole

5- Insulin

Answer & Comments

Answer: 1- Tacrolimus

Tacrolimus suppresses renin release, leading
to decreased aldosterone synthesis and
decreased potassium secretion in collecting
duct leading to hyperkalaemia.

[ Q: 2169 ] MRCPass - 2011 January

A 25 year old woman has a history of
recurrent urinary tract infection as a child.

Her mother has a history of hypertension and
was told that her kidneys were 'damaged'. An
ultrasound of the patient showed scarring in
both kidneys.

What is the most likely diagnosis?

1- Autosomal dominant polycystic kidney
disease

2- Reflux nephropathy

3- Renal cell carcinoma

4- Diabetic nephropathy

5- IgA nephropathy

Answer & Comments

Answer: 2- Reflux nephropathy

Urine reflux is the most common cause of
chronic pyelonephritis and can lead to
nephropathy.

The risk factors include a personal or family
history of reflux. Ultrasound can identify renal
scarring if the degree is moderate to severe.

[ Q: 2170 ] MRCPass - 2011 January

A 30 year old patient has been
diagnosed as having likely breast cancer on a
mammogram.

Which one of the following blood tests is
useful as a prognostic marker for this patient?

1- Ca 125

2- Ca 19-9

3- Ca 15-3

4- Alpha feto protein

5- Human Chorionic Gonadotrophin

Answer & Comments

Answer: 3- Ca 15-3

CA 15-3 (also known as MUC1) is the most
widely used serum marker in breast cancer.

Studies have shown that patients with high
preoperative levels of CA 15-3 (>30.4 U/mL)
had a worse outcome than patients with low
levels of the marker.

[ Q: 2171 ] MRCPass - 2011 January

A 46-year-old male with no previous
medical history was admitted to hospital with
a severe, dull chest pain, radiating to both
shoulders. The chest pain is worse with

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inspiration. A few days before, he had
suffered a minor cold. He was stable
haemodynamically and cardiac examination
showed a nondisplaced point of maximal
intensity and normal SI and S2. There were no
extra heart sounds or cardiac murmurs. The
ECG showed wide spread saddle shaped ST
elevation. Full blood count, erythrocyte
sedimentation rate, blood electrolytes and
serum creatinine were normal. Troponin
result was positive.

Whot is the diagnosis?

1- Myocardial infarction

2- Musculoskeletal chest pain

3- Pulmonary embolus

4- Costochondritis

5- Pericarditis

Answer & Comments

Answer: 5- Pericarditis

The diagnosis is acute pericarditis, which is
likely to be due to a viral infection e.g.
coxsackie virus. The mainstay of therapy is
nonsteroidal anti-inflammatory drugs
(NSAIDs). Aspirin, indomethacin, naproxen
and diclofenac are examples. Corticosteroids
should be reserved for patients whose
symptoms are refractory to NSAID therapy.

[ Q: 2172 ] MRCPass - 2011 January

A 36-year-old woman presented
with haemorrhage, peri-rectal bleeding and
easy bruising.She has a history of chronic
lymphocytic leukaemia and has been on
Fludarabine, chlorambucil, cyclophosphamide
and rituximab treatment. Physical
examination revealed multiple bruses, right
cervical lymphadenopathy, and

hepatosplenomegaly. Laboratory data showed
haemoglobin 5.9 g/dL, while blood cell count
(WBC) 92 x 10 9 /L with circulating blasts, and
platelet count 34 x 10 9 /L. Her blood group is 0
Rh Negative.

Whot type of blood should be prescribed?

1- Irradiated blood

2- Group A blood

3- Group B blood

4- Rh negative

5- CMV negative

Answer & Comments

Answer: 1- Irradiated blood

Irradiated blood reduces the risk of Grave
versus Host disease, and is recommended for
patients who have had stem cell
transplantation or haematological malignancy
with immunosuppression due to
chemotherapy.

Patients with blood group 0 can only receive
blood of Group 0.

[ Q: 2173 ] MRCPass - 2011 January

A 22-year-old woman presents with
a fall and was found at home. She had a past
history of coronary artery bypass grafting,
stroke and diabetes. Her usual drugs include
ramipril, aspirin and atenolol. On admission,
she had a blood pressure of 95/60 mmHg and
temperature of 34 C. She was very weak and
unable to get out of bed.

Cardiovascular, respiratory and abdominal
examination were unremarkable. Urine
dipstick shows protein ++, blood +++, white
cells +.

Whot test should be done?

1- Magnesium

2- Creatine kinase

3- International normalised ratio

4- Troponin

5- Brain natriuretic peptide

Answer & Comments

Answer: 2- Creatine kinase

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This patient is likely to have been on the floor
due to weakness and may have
rhabdomyolysis.

The urine dipstick may demonstrate blood,
although the true test is of myoglobin levels. A
significantly elevated creatine kinase enzyme
would be a reasonable indicated of
rhabdomyolysis, and the patient should be
kept well hydrated.

Monitoring of renal function and urine output
would be important.

What is the mechanism of action of
carbimazoie?

1- Thyroperoxidase enzyme inhibitor

2- Thyroid stimulating hormone inhibitor

3- Thyroxine binding action

4- Inhibits iodination of thyroxine

5- Inhibition of enzyme 5'-deiodinase

Answer & Comments

Answer: 4- Inhibits iodination of thyroxine

[ Q: 2174 ] MRCPass - 2011 January

A 20 year old man has noticed some
lesions around the genital area and seeks
consultation. On examination, there are
several popular lesions around the shaft of the
penis and scrotum. Genital warts are
confirmed as the diagnosis.

What treatment should be offered?

1- Augmentin

2- Podophyllotoxin

3- Acyclovir

4- Ketoconazole

5- Permethrin

Carbimazoie is an aitithyroid agent that
decreases the uptake and concentration of
inorganic iodine by the thyroid.

It prevents the thyroid peroxidase enzyme
from coupling and iodinating the tyrosine
residues on thyroglobulin, hence reducing the
production of the thyroid hormones T3 and
T4.

Propylthiouracil inhibits the thyroperoxidase
enzyme

Answer & Comments

Answer: 2- Podophyllotoxin

Genital warts are caused by human
papillovirus infection.

First-line treatment (0.15% cream) for soft
warts in accessible sites, e.g. vaginal introitus,
under foreskin includepodophyllotoxin and
cryotherapy.

^ [ Q: 2175 ] MRCPass - 2011 January

#1 -

# A 28 year old lady was prescribed

carbimazoie as she was diagnosed with
Grave's disease.

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[ Q: 2176 ] MRCPass - 2011 May

A 46 year old lady presented to her
physician with complaints of weakness and
headaches for several months.

At presentation, she was found to have severe
hypertension with blood pressure 190/110
mmHg.

Blood results are:

sodium 149 mmol/l

potassium 2.9 mmol/l

urea 7 mmol/l

creatinine 100 |imol/l

Renin 4.1 ng/L (13.6 -70)

Plasma aldosterone 2170 pmol/L (110-800)

Urine Adrenaline 52 (<80 nmol/24 hours)

Urine Noradrenaline 650 (<780 nmol/24
hours)

Urine Dopamine 2100 (<3500 nmol/24 hours)

Urine Cortisol 210 (100-300) nmol/24 hours

An MRI abdomen showed a well defined 1 cm
x 1.5 cm mass in the right supra-renal gland.

What is the likely diagnosis?

1- Phaeochromocytoma

2- Multiple endocrine neoplasia I

3- Renal artery stenosis

4- Cushing's syndrome

5- Conn's syndrome

Answer & Comments

Answer: 5- Conn's syndrome

The diagnosis is Conn's syndrome.

Conn syndrome is characterized by increased
aldosterone secretion from the adrenal
glands, suppressed plasma renin activity
(PRA), hypertension, and hypokalemia as seen
in the case above.

Routine laboratory studies can show
hypernatremia, hypokalemia, and metabolic

alkalosis resulting from the action of
aldosterone on the distal tubule of the kidney.

^ [Q: 2177] MRCPass-2011 May

A -

* A 41 year old, chronic hemodialysis
patient received a living donor kidney
transplant from an HLA-identical sibling.

The transplant recipient had no antibodies to
CMV at the time of transplantation, whereas
the donor was CMV positive. The
posttransplant immunosuppression therapy
included tacrolimus 3 mg twice a day,
mycophenolate mofetil 1000 mg twice a day,
and prednisone 20 mg every day.

On posttransplant day 39, the patient was
admitted to the inpatient transplant service,
complaining of abdominal flank pain, nausea
and experiencing malaise. She had been
having intermittent fevers for the last week.
At that time, the patient's white blood cell
count was 5.8 k/uL and her platelet count was
within normal limits. Her creatinine rose from
pre transplant 100 ul/l to 145 ul/l. A renal
biopsy showed acute rejection. Subsequent to
that biopsy result, her CMV viral load (PCR)
was also found to be positive (8870
copies/mL).

What should be done?

1- Increase dose of tacrolimus

2- Increase dose of prednisolone

3- Commence ribavirin

4- Commence ganciclovir

5- Perform an OGD

Answer & Comments

Answer: 4- Commence ganciclovir

The timing of events and CMV serology
suggests that the deterioration is due to CMV
infection.

CMV infection is a multifaceted phenomenon
with a variety of direct and indirect effects in
the organ transplant recipient. The

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symptomatology for clinical infectious disease
(ie, fever, pneumonia, Gl ulcers, hepatitis)
ranges from the mild, subclinical case to life-
threatening multi-organ disease. Most cases
of symptomatic CMV infection can be
characterized by a self-limiting syndrome of
episodic fever spikes for a period of 3 to 4
weeks, arthralgia, fatigue, anorexia,
abdominal pain, and diarrhoea. Ganciclovir is
the most commonly used agent for the
prevention and also treatment of CMV
infection. The treatment dose is 5 mg/kg
intravenously every 12 hours.

Hyperacute rejection of the renal allograft
happens within hours of the transplant, and it
occurs when circulating, preformed, cytotoxic,
antidonor antibodies directed to the ABO
blood group antigens or to the donor HLA
class I antigens are present. No treatment
exists, and nephrectomy is indicated.

Accelerated acute rejection is a very early,
rapidly progressive, aggressive rejection
reaction dependent on T cells.

had had no abdominal pain and had started to
vomit the day before presentation. On
examination he was dehydrated and mildly
disorientated. He had a tachycardia of
140/min, and a blood pressure of 90/70
mmHg, with a postural drop to 60/30 mmHg.
His abdomen was soft and non-tender, with
tinkling bow el sounds.

Sodium 140 mmol/l (135-145 mmol/l),
Potassium 7.6 mmol/l (3.5-5.0
mmol/l),Chloride 83 mmol/l (95-110 mmol/l)
Bicarbonate 16 mmol/l (22-26 mmol/l) Urea
32 mmol/l (2.8-8.9 mmol/l) Creatinine 360
[irnol/l (75-115 mmol/l) Glucose 4.9 mmol/l
(3.9-6.1 mmol/l) pH 7.20 (7.35-7.45 pH units).
An ECG shows broad complexes and tall T
waves.

Whot should be given next?

1- Frusemide

2- Haemodialysis

3- Sodium bicarbonate

4- Insulin and dextrose

It can occur within the first week of
transplantation. Immediate therapy with anti-
T-cell antibodies and pulse corticosteroids
may reverse the process. Approximately 50%
of cases can be salvaged. Chronic rejection is a
slow and progressive deterioration in renal
function characterized by histologic changes
involving the renal tubules, capillaries, and
interstitium. The precise mechanism of this
disease is poorly defined and is an area of
intense study. Application of conventional
antirejection agents, such as corticosteroids or
anti-T-cell antibodies, does not appear to alter
the progressive course. Unfortunately, this is a
major cause of kidney allograft loss, occurring
later than 2 years posttransplantation.

[ Q: 2178 ] MRCPass - 2011 May

A 71-year-old man was admitted
with a 3-w eek history of general debility and
diarrhoea, passing copious amounts of watery,
brow n stool through the day and night. He

5- Calcium gluconate

Answer & Comments

Answer: 5- Calcium gluconate

The important management step is to provide
cardioprotection in the form of calcium
gluconate, particularly when there are ECG
changes.

Following this the patient should have insulin
and dextrose, as well as consideration for
haemodialysis if the potassium does not
improve. Sodium bicarbonate therapy should
be reserved for the treatment of severe
metabolic acidosis (i.e., pH below 7.2 or a
bicarbonate level below 10 to 15 mmol per L)
with or without associated hyperkalemia.

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^ [ Q: 2179 ] MRCPass - 2011 May

/ - - - — - — -

# A 53-year-old female presented with

two month history of an itchy rash which first

appeared on her wrist and gradually her neck

and upper arms. She also complained of a sore

tongue and lethargy which had become

increasingly severe over the past 5 months.

There was no relevant past medical, family or

drug history.

On examination the mucous membranes were
pale, the tongue appeared smooth and shiny
with several superficial erosions on the upper
surface. There were annular atrophic
pigmented lesions on the abdomen, lumbar
region, back of the neck and scattered over
other areas on the trunk.

What is the most likely diagnosis?

1- Guttate psoriasis

2- Granuloma annulare

3- Pityriasis versicolor

4- Pityriasis rosea

5- Lichen planus

Answer & Comments

Answer: 5- Lichen planus

There is an increased incidence of lichen
planus in several diseases in which there is
autoimmune phenomena.

Lichen planus (LP) is a pruritic, papular
eruption characterized by its violaceous color;
polygonal shape; and, sometimes, fine scale.

hyperkeratosis, onycholysis, and longitudinal
melanonychia can result from LP.

Oral lichen planus

Lichen Planus on flexural surface

The initial lesion is usually located on the
flexor surface of the limbs, such as the wrists.

After a week or more, a generalized eruption
develops with maximal spreading within 2-16
weeks. Oral lesions may be asymptomatic or
have a burning sensation, or they may even be
painful if erosions are present.

Characteristic fine, white lines, called
Wickham's striaw , are often found on the
papules. Hyperpigmentation, subungual

[ Q: 2180 ] MRCPass - 2011 May

A 60 year old man presents with leg
weakness and breathlessness. He had bilateral
lower limb paraesthesias followed by bilateral
progressive leg weakness and difficulty in
walking. The symptoms have worsened over
the last 5 days. He reported an episode of an
upper respiratory tract infection 3 weeks prior
to the onset of the neurological symptoms. A
lumbar puncture was performed.

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Cerebrospinal fluid revealed increased protein
but normal white blood cell count.

How should his respiratory function be
monitored?

1- PEFR

2- Vital capacity

3- Tidal volume

4- Arterial blood gases

5- Chest expansion

Answer & Comments

Answer: 2- Vital capacity

The history here of ascending limb weakness
following a recent infection is typical of
guillain barre syndrome (GBS).

A typical GBS patient presents with rapidly
ascending symmetrical weakness, which may
progress to respiratory failure in 30% of
patients. Vital capacity measurements are
important in Guillain Barre syndrome.

Patients with an FVC less than 15-20 mL/kg
indicate compromise and need to be observed
for the need for ventilation.

Transferrin saturation (TS) is the most
effective and inexpensive screening test for Fe
overload.

If the TS is > 45%, the test should be repeated,
together with serum ferritin. If TS (w ith or
without high ferritin) is raised, HFE genes
should be determined.

[ Q: 2182 ] MRCPass - 2011 May

A 18-year-old woman presented
feeling unwell to the accident and emergency
department of a district general hospital. She
has been attending a summer camp teaching
children basic outdoor skills over the last
week. She complained of a widespread rash,
dry cough and sore eyes. She has no relevant
past medical history and does not take regular
medications. On examination, the
temperature is 38 C. She has a widespread
maculopapular rash with confluence. Her eyes
are red and he had bilateral crepitations in the
chest.

What is the likely diagnosis?

1- HIV seroconversion

2- Measles

[ Q: 2181 ] MRCPass - 2011 May

A 26 year old patient presents to the
clinic for advice. His brother has recently been
diagnosed with haemochromatosis.

Which one of the following is the most useful
screening test?

1- Ferritin

2- HFE gene analysis

3- Ultrasound of the liver

4- Liver iron levels

5- Transferrin saturation

Answer & Comments

Answer: 5- Transferrin saturation

3- Mumps

4- Typhoid fever

5- Chickenpox

Answer & Comments

Answer: 2- Measles

Measles is a highly communicable acute
disease that is caused by the airborne
transmission of a paramyxovirus.

In its classical form it is characterized by high
fever, dry cough, coryza and conjunctivitis.
Koplik's spots are rarely seen but are
pathognomonic of disease. The characteristic
rash appears several days after the onset of
fever. The rash is maculopapular and
erythematous, which spreads from the head
to the torso and the extremities.

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[ Q: 2183 ] MRCPass - 2011 May

A 60 year old lady has investigations
for renal impairment (creatinine 220 umol/l).
She has a previous history of hypertension,
peripheral vascular disease and osteoarthritis.
She has been taking diclofenac for 6 years and
penicillamine for the past 2 years (both drugs
were stopped 6 months ago). Her blood
pressure is 100/60 mmHg and her estimated
GFR is 6 mls/min/1.73m2. Results are:

Urine : protein +, blood -ve

Ultrasound of kidneys : right 8.6 cm, left 9.4
cm in length.

What is the likely diagnosis?

1- Ischaemic nephropathy

2- Analgesic nephropathy

3- Interstitial nephritis

4- Minimal change nephropathy

5- Diabetic nephropathy

Answer & Comments

Answer: 1- Ischaemic nephropathy

The likely diagnosis is renovascular disease
due to the small kidney size.

There is only 1+ Proteinuria, which makes
glomerulonephritis less likely. The other clues
are the history of hypertension and the
vascular risk factors for renovascular disease.

[ Q: 2184 ] MRCPass - 2011 May

A 35 year old lady has started
working in a factory 2 months ago. She
complains of breathlessness and wheeziness.
The GP refers her to the respiratory clinic for
assessment.

What investigation is most appropriate to
diagnose occupational asthma?

1- Measure peak flows over 2 weeks

2- Serial peak flow measurements at home
and work

3- Skin prick tests

4- Lung function test

5- Vitalogram

Answer & Comments

Answer: 2- Serial peak flow measurements at
home and work

Lung function tests and reversibility will help
to confirm asthma.

For diagnosis of occupational asthma, serial
measurements of peak expiratory flow rate at
home and at work: this is often the most
appropriate first step.

Measurements should be made every two
hours from waking to sleeping for four weeks,
keeping treatment constant and documenting
times at work. There should be at least 3
consecutive work days and 3 days away from
work included in the measurements, (as per
Guidelines from the British Occupational
Health research on Occupational Asthma).

[ Q: 2185 ] MRCPass - 2011 May

A 42 year old man presented to his
GP because of painful blisters on the backs of
his hands in the summer. He also had a similar
rash on the forehead. His face and forehead
were covered with thickly wrinkled,
hyperpigmented skin. The patient's urine was
reddish orange.

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What is the likely diagnosis?

1- Porphyria cutanea tarda

2- Pemphigoid

3- Contact dermatitis

4- Pityriasis rosea

5- Epidermolysis bullosa

Answer & Comments

Answer: 1- Porphyria cutanea tarda

In porphyria cutanea tarda, the urine
fluoresces pink to red.

Porphyria Cutanea Tarda

Porphyria cutanea tarda's onset is typically
during the

fourth or fifth decade of life. The disease
tends to develop, recur, or worsen during the
spring and summer, when exposure to
sunlight is greatest (ie photosensitivity).
Though blisters are the most common skin
manifestations of PCT, other skin
manifestations like hyperpigmentation and
hypertrichosis (mainly on top of the cheeks)
also occur.

[ Q: 2186 ] MRCPass - 2011 May

A 31-year old woman has a history of
3 previous pregnancies all of which ended in
spontaneous abortion between 18 and 24
weeks. The last pregnancy was complicated by
episodes of purpura and thrombocytopenia
with platelet counts of around 20 x 10 9 /l. A
diagnosis of systemic lupus erythematosus
(SLE) has been diagnosed on the basis of a
positive anti-nuclear factor and anti ds DNA
binding of 70%. Her symptoms were
occasional attacks of arthralgia and rash. She
is being seen in clinic for evaluation.

Which one of the following antibody tests is
most appropriate for diagnosing the cause of
her abortions?

1- Anti La

2- Anti Ro

3- Anti cardiolipin

4- Anti Scl-70

5- Anti centromere

Answer & Comments

Answer: 3- Anti cardiolipin

Cardiolipin is a phospholipid to which the
Anticardiolipin reacts with.

The lupus anticoagulant is an immunoglobulin,
IgG or IgM, which also binds to phospholipids.

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Patients with systemic lupus erythematosus
(SLE) are more likely to develop a lupus
anticoagulant than the general population as
in the case above.

Both lupus anticoagulant and anticardiolipin
antibody are associated with each of the
clinical manifestations of the antiphospholipid
syndrome, which is associated with arterial
and venous thrombosis, and recurrent
spontaneous abortions.

There was also pain and temperature
sensation loss in the left thigh area.

What is the most likely diagnosis?

1- Motor neuron disease

2- Multiple sclerosis

3- Friedrich's ataxia

4- Poliomyelitis

5- Spinal meningioma

[ Q: 2187 ] MRCPass - 2011 May

A 40 year old severe asthmatic is
assessed for hip pain. He takes salbutamol and
atrovent inhalers, and has been on multiple
courses of high dose prednisolone. He is
complaining of hip pain for 8 weeks and is
unable to weight bear. He gives no history of
trauma.

What is the most likely diagnosis?

1- Osteomyelitis

2- Osteoporosis with fracture

3- Avascular necrosis

4- Sickle cell crisis

Answer & Comments

Answer: 5- Spinal meningioma

Brow n-Sequard syndrome is an incomplete
spinal cord lesion characterized by a clinical
picture reflecting hemisection of the spinal
cord.

The clinical features are:

-Unilateral upper motor neuron weakness
below the level of the lesion

-Ipsilateral loss of tactile discrimination,
vibratory, and position sensation below the
level of the lesion

5- Osteoarthritis

Answer & Comments

Answer: 3- Avascular necrosis

A painful limb for no apparent reason would
fit avascular necrosis, which is predisposed to
by high dose steroids.

[ Q: 2188 ] MRCPass - 2011 May

A 45-year-old woman has presented
with weakness in right lower limb that had
gradually progressed over the previous 8
months.

She has had difficulty in walking for the last 2
months. On examination, she has increased
tone, weakness of knee and ankle flexion and
extension, and upgoing plantar on the right.

-Contralateral loss of pain and temperature
sensation.

[ Q: 2189 ] MRCPass - 2011 May

A 75 year old man presents with a
sw elling over the right side of the temple. The
lesion was noticed 4 years ago and was little
changed. On examination it was smooth, shiny
and non pigmented.

What is the probable diagnosis?

1- Trophic ulcer

2- Basal cell carcinoma

3- Lupus vulgaris

4- Sebaceous cyst

5- Squamous cell carcinoma

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Answer & Comments

Answer: 2- Basal cell carcinoma

Basal cell carcinomas can have many different
appearances: a red patch or irritated area; a
smooth, shiny and waxy looking bump; a
white or yellow scar-like area; a smooth
reddish grow th; or an open sore that won't
heal, bleeds or oozes.

They are slow growing as described in this
case, and rarely metastasise.

Basal Cell Carcinoma

^ [ Q: 2190 ] MRCPass - 2011 May

fi -

# A 35-year-old woman had initially
presented with cold hands. Her complaint
usually occurred on cold days or in cold water,
initially presenting as pale and cold digits
which progressed to painful, purple finger tips.
In the last 5 years, she complained of
dysphagia and heartburn. The patient has a
history of hypertension.

On physical examination, her blood pressure
was 150/90 mmHg, and her heart rate was 90
/min. Skin hardness and thickening were
palpated at the fingers and toes. X rays of
bilateral hand and foot showed cutaneous
calcifications, especially near the fingertips.

Which one of the following tests is likely to be
correlated with the diagnosis?

1- ANA

2- DsDNA

3- Anti centromere antibody

4- Anti smooth muscle antibody

5- Anti Ul ribonucleoprotein (RNP)

Answer & Comments

Answer: 3- Anti centromere antibody

The limited cutaneous form of systemic
scleroderma (IcSSc) is often referred to as
CREST syndrome.

"CREST" is an acronym for the five main
features: Calcinosis, Raynaud's syndrome,
Esophageal dysmotility, Sclerodactyly,
Telangiectasia. The anti-centromere antibody
is more specific for the CREST syndrome than
diffuse progressive systemic sclerosis
(scleroderma).

The Anti Ul ribonucleoprotein (RNP) is a
marker for mixed connective tissue disease
(MCTD) which is characterized by the
presence of high titers of a distinct
autoantibody in combination with clinical
features commonly seen in systemic lupus
erythematosus (SLE), scleroderma, and
polymyositis (referred to as overlap

syndrome)

[ Q: 2191 ] MRCPass - 2011 May

A 19 year old lady had a 5 kg weight
loss recently which made her family
concerned about her. She moved from school
to college recently and had difficulty coping .
She was having amenorrhoea for the last 3
months.

Which one finding is likely to be present?

1- Acanthosis nigricans

2- Fine hair on the face & body

3- Hirsutism

4- Increased LH/FSH ratio

5- Hyperthermia

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Answer & Comments

Answer: 2- Fine hair on the face & body

The features are suggestive of Anorexia
nervosa.

Possible physical and biochemical features
are:

emaciation

■ hair changes e.g. lanugo; hair loss
from the scalp

■ amenorrhoea
gonadotrophins - low FSH, LH

few months and presents to the neurology
clinic for review . Otherwise she is only on oral
contraceptive pill.

Which of the following is the best alternative?

1- Carbamazepine

2- Phenytoin

3- Topiramate

4- Lamotrigine

5- No treatment

Answer & Comments

Answer: 1- Carbamazepine

T3 - low ; T4, TSH - normal

[ Q: 2192 ] MRCPass - 2011 May

A 19-year-old female was admitted
after severe paracetamol overdose. She was
treated with IV N-acetylcysteine.

N-acetylcysteine acts by replenishing which
compound?

1- Arginine

2- Cysteine

3- Lysine

4- Glutathione

5- Methionine

Answer & Comments

Answer: 4- Glutathione

Treatment of paracetamol overdose with N-
acetylcysteine is well established.

The effect is to enhance glutathione stores
and to promote the elimination of
paracetamol metabolites.

[ Q: 2193 ] MRCPass - 2011 May

A 21 year old female has been on
sodium valproate 200mg od for epilepsy. She
noticed weight gain and ataxia over the past

Sodium valproate is the drug of first choice for
primary generalized epilepsy, valproate has a
very wide spectrum and is effective in most
seizure types, including myoclonic seizures.

It has multiple mechanisms of anticonvulsant
effects, including increasing gamma-
aminobutyric acid (GABA) levels in brain as
well as T-type calcium channel activity.This
older antiepileptic drug is used as a second-
choice agent along with phenytoin, but
phenytoin is not favoured in the long term
due to side effects of osteopenia and
cerebellar ataxia.

Both sodium valproate and carbamazepine are
older generation antiepileptics. If both of
these have been tried and contraindicated
due to side effects, then newer generation
antiepileptics such as topirimate and
lamotrigine should then be used.

^ [ Q: 2194 ] MRCPass - 2011 May

f* -

# An 18 year old man who has had
acne for 1 year has been on minocycline
orally. The case has been getting worse
despite the drug. He currently still has
pustules and scarring on the face.

Which treatment should be started next?

1- Oxytetracycline

2- Isotretinoin

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3- UV light

4- Prednisolone

5- Dithranol

Answer & Comments

Answer: 2- Isotretinoin

Patients who are on long term tetracyclines
and not responding should also have
isotretinoin tablets.Oral isotretinoin is
marketed under various trade names, the
most common ones being Roaccutane.

Isotretinoin is used only after other acne
treatments fail to produce results. Treatment
of acne usually begins with topical
medications (e.g., benzoyl peroxide), followed
by oral antibiotics (or a combination) and
finally isotretinoin therapy, because other
treatments, while less effective than
isotretinoin, are thought to be associated with
fewer adverse effects and lower cost.

Idiopathic Parkinson's disease is characterised
by tremor, rigidity and bradykinesia (which is
typically asymmetrical).

There are also features of postural instability,
a mask like face and a shuffling gait.

Autonomic dysfunction is often associated
(mild postural hypotension)

[ Q: 2196 ] MRCPass - 2011 May

A 50 year old patient with
Parkinson's disease has been established on
ropinirole.

Whot is its mechanism of action?

1- Dopamine agonist

2- Monoamine oxidase inhibitor

3- Antiviral drug

4- Catechol - o - methyl transferase inhibitor

5- Anticholinergic drug

[ Q: 2195 ] MRCPass - 2011 May

A 60 year old woman presented with
a 10-year history of increasing stiffness and
immobility which have led to multiple falls. On
examination, she had a lying BP of 130 / 80
mmHg and a standing BP of 125 / 70 mmHg.
She had a mask like facies, bradykinesia, and
resting a tremor in both of her arms. The
tremors and rigidity was worse on the right
side. There was also short-term memory loss.

Answer & Comments

Answer: 1- Dopamine agonist

--careldopa (contains L dopa) is often the first
medication used to increase dopaminergic
activity in the basal ganglia.

-Benztropine is an anticholinergic drug, used
typically when there are tremors.

-Entecapone is a Catechol - o - methyl
transferase inhibitor.

What is the diagnosis?
1- Lewy body dementia

-Selegiline is an MAO inhibitor (potentiates
dopamine)

2- Alzheimer's disease

3- Parkinson's disease

4- Multi system atrophy

5- Progressive supranuclear palsy

-Amantadine is an antiviral drug (also
potentiates dopamine) used as a second line
drug.

-Apomorphine is a dopamine agonist used for
on-off fluctuations.

Answer & Comments

Answer: 3- Parkinson's disease

-Ropinirole is a dopamine agonist (D2,D3, D4)
which is used in conjunction or in place with
levodopa.

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[ Q: 2197 ] MRCPass - 2011 May

Which one of the following is a
marker of bod prognosis in acute
lymphoblastic leukaemia?

1- Pre-B phenotype

2- Age of < 20 years

3- Initial white cell count of 18 x 10 9 /l

4- Female sex

5- BCR-Abl gene

Answer & Comments

Answer: 5- BCR-Abl gene

Acute lymphoblastic leukaemia (ALL) is most
common in childhood with a peak incidence at
4-5 years of age, and another peak in old age.

Some prognostic factors are:

inhibitors (such as imatinib and sunitinib) are
important drugs against a variety of cancers
including in CML, and sometimes in Ph-
positive acute lymphoblastic leukemia
(Ph+ALL)

[ Q: 2198 ] MRCPass - 2011 May

A 54-year-old woman presents with
periods of sweats and tremors which are
relieved by eating. She has gained
approximately 6 kg in weight in the last 2
years. Her BM is 4.5. Blood tests are: Hb 13
g/dl, MCV 78 fl, WCC 7 x 10 9 /l, platelets 200 x
10 9 /l, sodium 135 mmol/l, potassium 4.7
mmol/I, urea 5 mmol/l, creatinine 100 pmol/l,
TSH - 3.3 (0.3-4) mU/l, free T4 -20 (10-24)
pmol/l.

What is the most appropriate investigation?

1- 72 hour fast

Sex: females tend to fare better than males.

2- CT scan of pancreas

Age at diagnosis: children between 1-10 years
of age are most likely to develop ALL and to be
cured of it.

Cytogenetics: Philadelphia translocation,

t(9;22) is a bad prognostic factor. (Philadelphia
translocation, t(9;22) - good prognosis in CML,
poor prognosis in AML + ALL) The exact
chromosomal defect in Philadelphia
chromosome is a translocation. Parts of two
chromosomes, 9 and 22, sw ap places. The
result is that a fusion gene is created by
juxtapositioning the Abll gene on
chromosome 9 (region q34) to a part of the
BCR ("breakpoint cluster region") gene on
chromosome 22 (region qll). The result of the
translocation is the oncogenic BCR-ABL gene
fusion. Because the Abl gene expresses a
membrane-associated protein, a tyrosine
kinase, the BCR-Abl transcript is also
translated into a tyrosine kinase, adding a
phosphate group to tyrosine. Although the
BCR region also expresses serine/threonine
kinases, the tyrosine kinase function is very
relevant for drug therapy. Tyrosine kinase

3- MRI of the brain

4- Insulin C-peptide concentration

5- Oral glucose tolerance test

Answer & Comments

Answer: 1- 72 hour fast

This patient has symptoms suggestive of
hypoglycaemia which are relieved by
carbohydrate.

The likely cause is an insulinoma which is an
insulin secreting pancreatic tumour.

Measurement of C-peptide is useful in
excluding factitious hypoglycaemia from self
injection of insulin. Insulin preparations do not
contain C-peptide.

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[ Q: 2199 ] MRCPass - 2011 May

A 65-year-old female is brought to
A&E by her family, who are concerned about
her increasing lethargy and confusion over the
past 3 days. There is a history of diarrhea in
the preceding few days. On examination she is
found to be pyrexial at 38°C. Breath sounds
are clear and there is mild tenderness in the
lower abdomen.

Blood tests results show :

Hb 8.6 g/dl

WCC 12 x 10 9 /l

Platelets 65 x 10 9 /l

sodium 138 mmol/I

potassium 4.7 mmol/I

Urea 22.1 mmol/l

Creatinine 366 mmol/l

Whot is the likely causative organism?

1- Staphylococcus aureus

2- Neisseria Meningitidis

3- Legionella

4- Leptospira

5- E coli 0157

Answer & Comments

Answer: 5- E coli 0157

The patient has haemolytic uraemic
syndrome.

It is characterized by the triad of
microangiopathic hemolytic anemia,
thrombocytopenia, and acute renal failure.
Diarrhea (E coli 0157) and upper respiratory
infection are the most common precipitating
factors. The hallmark of HUS in the peripheral
smear is the presence of schistocytes
(fragmented, deformed red cell fragments)
and helmet-shaped RBCs.

[ Q: 2200 ] MRCPass - 2011 May

A 45 year old lady, presented with a
history of pain in the upper abdomen and an
ultrasound showed gallstones.

She underwent a laparoscopic
cholecystectomy. Initially she felt well but
started to develop frequent diarrhoea. In view
of the history, what treatment is she likely to
need?

1- Cholestyramine

2- Azathioprine

3- Bromocriptine

4- Pancreatin

5- Amitriptyline

Answer & Comments

Answer: 1- Cholestyramine

The term postcholecystectomy syndrome
(PCS) describes the presence of symptoms
after cholecystectomy.

Two types of problems may occur. The first
problem is continuously increased bile flow
into the upper Gl tract, which may contribute
to esophagitis and gastritis. The second
consequence is related to the lower Gl tract,
where diarrhea and colicky lower abdominal
pain may result which is described in the case
above. Cholestyramine has been of help for
patients with diarrhea. It is a bile acid
sequestrant, which binds bile in the
gastrointestinal tract to prevent its
reabsorption.

It has been used in cases of pruritus due to
jaundice. Cholestyramine is also used to
prevent diarrhea in Crohn's disease patients
who have undergone post-ileal resection. The
terminal portion of the small bow el (ileum) is
where bile acids are reabsorbed.

[ Q: 2201 ] MRCPass - 2011 May
An 81 year old woman was found to

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be anaemic by the GP following complaints of
feeling generally unwell. She was referred to
the haematology department, where
subsequent investigations found that she had
idiopathic myelofibrosis.

Whot is the commonest presenting symptom
for myelofibrosis?

1- Haemoptysis

2- Splenomegaly

3- Diarrhoea

4- Fatigue

5- Rectal bleeding

Answer & Comments

Answer: 4- Fatigue

The most common symptoms at presentation
for myelofibrosis include fatigue, fever,
bruising, and shortness of breath.

Splenomegaly is associated, but not the most
common presentation.

^ [ Q: 2202 ] MRCPass-2011 May

/ -

* A 42 year old woman presents with

confusion, headache and neck stiffness. She
has no previous past medical history of note.
When she arrived at the admissions unit she
was witnessed to have a generalised seizure
which spontaneously resolved. She has a
temperature of 38.5 C. A lumbar puncture was
performed. Results showed:

CSF pressure: 12 cm

glucose - 3.7 mmol/l

protein < 0.55 g/l

white cells 290 (95% lymphocytes)

An MRI scan showed high signal in the
temporal lobes including hippocampal
formations and parahippogampal gyrae and
right inferior frontal gyrus.

Whot is the likely diagnosis?

1- Pneumococcal meningitis

2- Guillain Barre syndrome

3- TB meningitis

4- Poliomyelitis

5- Herpes simplex virus encephalitis

Answer & Comments

Answer: 5- Herpes simplex virus encephalitis

In Herpes simplex virus (HSV) encephalitis, a
presentation with fevers, confusion or a
change in personality is common.

The CSF white cell count is elevated with
lymphocytosis. The majority of cases of herpes
encephalitis are caused by herpes simplex
virus-1 (HSV-1). The MRI typically shows high
signal changes in the T2 weighted images in
the temporal lobe areas, in HSV encephalitis.
Treatment is with iv acyclovir.

HSV encephalitis

[ Q: 2203 ] MRCPass - 2011 May

A 60 year old lady presents with
blurred vision acutely. Further questioning
revealed that she had episodes of slurred
speech suggesting that she had 3 episodes of
transient ischaemic attacks in the last 2 weeks.
She has a history of hypertension. An ECG
showed sinus rhythm. Carotid dopplers
showed: right sided carotid artery normal, left
sided 50% occlusion.

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What is the best monogement?

1- Right sided carotid endarterectomy

2- Left sided carotid endarterectomy

3- Bilateral carotid endarterectomy

4- Carotid angioplasty

5- Thrombolysis

Answer & Comments

Answer: 2- Left sided carotid endarterectomy

Indications for carotid endarterectomy are:
Asymptomatic patients with greater than 70%
stenosis or symptomatic patients with > 50%
stenosis.

A 39-year-old male, was diagnosed
with seropositive rheumatoid arthritis at the
age of 20.

In addition to prednisolone therapy, several
different disease-modifying drugs were given
over the following years, including
sulfasalazine, oral gold, resochine,
methotrexate, and TNF-inhibitors. He smokes
15 cigarettes a day.

H presented to the hospital with shortness of
breath and intermittent nausea. On clinical
examination, he showed signs of extensive
rheumatoid arthritis, most marked on hand,
foot, and shoulder joints as well as rheumatic
nodules on both elbow s. His heart rate was
regular at 105/min, blood pressure was
120/70 mm Hg. He had a raised JVP of 6 cm
and a left parasternal heave. He also had a
palpable liver and moderate ankle oedema.
His second heart sound (P2) was loud. The
breath sounds are clear and heart size is
normal on the chest x ray.

An echocardiogram revealed normal left
ventricular systolic function, and both atria
were dilated.

What is the most likely diagnosis?

1- Pulmonary embolus

[ Q: 2204 ] MRCPass - 2011 May

2- Pulmonary fibrosis

3- Constrictive pericarditis

4- Aortic dissection

5- Aortic aneurysm

Answer & Comments

Answer: 3- Constrictive pericarditis

Constrictive pericarditis, an extra-articular
complication in RA patients, is predominantly
seen in males with active, seropositive
disease.

Echocardiography often reveals normal
ventricular function and atrial dilatation. Heart
catheterization reveals equalization of
elevated ventricular diastolic pressures and
normal systolic function. There may be signs
of right sided heart failure, as in the above
case.

[ Q: 2205 ] MRCPass - 2011 May

A 17 year old student is behaving
strangely and referred to the hospital. His
teacher reports that he was accused the
teacher of conspiring against him. He was also
hearing voices asking him to cut his own
throat. He has not been himself recently, with
low moods according to his family. On
examination, he looks apathetic and physical
examination is normal. Blood tests were
unremarkable, and urine testing showed
traces of cannabinoids.

What is the likely diagnosis?

1- Psychotic depression

2- Paranoid schizophrenia

3- Drug induced psychosis

4- Anxiety disorder

5- Obsessive compulsive disorder

Answer & Comments

Answer: 3- Drug induced psychosis

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It is well established that psychotic symptoms
may follow cannabis intake.

[ Q: 2206 ] MRCPass - 2011 May

A 55 year homeless man was found
collapsed at home and brought to the
emergency department. He was unable to give
a history. On examination, he smelled of
alcohol. Observations in A&E reveal a
temperature of 34 C, a pulse of 45 bpm
pressure of 110/80 mmHg. Dipstick urine
analysis shows Blood +++, protein +, glucose -
ve.

Some of his investigation results are listed
below:

sodium 135 mmol/I
potassium 4.5 mmol/I
urea 5 mmol/l
creatinine 300 |imol/l
AST 320 (1-31) U/l
LDH 800 U/L (110-230) U/L

As patient was found unconscious and
hypothermic he was likely to have sustained
muscle injury. The positive urinalysis caused
by myoglobin a muscle protein released
during muscle damage. High amounts of
myoglobin damages the renal tubules which
then leads to acute kidney injury.

[ Q: 2207 ] MRCPass - 2011 May

A 36-year-old woman presented
with an 8 week history of weight gain, acne,
hirsutes and weakness.

Examination confirmed florid Cushingoid
features, with truncal obesity, striae, buffalo
hump, acne, hypertension and proximal
myopathy. Biochemical investigations are
summarised in the table. Gross
hypercortisolaemia (unsuppressed by
dexamethasone), hyperglycaemia and
hypokalaemia suggested an ectopic ACTH
syndrome.

Computed tomographic (CT) imaging showed
normal pituitary and hypothalamus, mild
bilateral adrenal hyperplasia.

What is the most likely couse?

1- Pituitary adenoma

2- Adrenal adenoma

3- Small cell carcinoma

Whot likely couse of the raised serum
creatinine concentration?

1- Chronic renal failure

2- Dehydration

3- Hypothermia

4- Paracetamol poisoning

5- Rhabdomyolysis

Answer & Comments

Answer: 5- Rhabdomyolysis

The elevated serum creatinine likely to be due
to rhabdomyolsis.

4- Bronchial carcinoid

5- Colon carcinoma

Answer & Comments

Answer: 3- Small cell carcinoma

The presentation of ectopic ACTH syndrome is
usually with cushingoid states such as weight
gain, oedema, diabetes and proximal muscle
weakness.

Ectopic ACTH (not from the pituitary) is usually
associated with a small cell carcinoma of the
bronchus. Less common causes include thymic
tumours, pancreatic adenocarcinoma and
bronchial carcinoid

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^ [ Q: 2208 ] MRCPass - 2011 May

/ ■ —- *■ - ■ -

# A 76 year old lady develops diarrhea

following a course of antibiotics.

Which of the following antibiotics is most
commonly associated with pseudo¬
membranous colitis?

1- Quinolones

2- Cephalosporins

3- Macrolides

Answer & Comments

Answer: 2- Check compliance of patient

This is a new ly diagnosed patient who was
started on thyroxine.

Levels show a low thyroxine level and TSH
remains high. This suggests undertreatment
but compliance of the treatment should be
evaluated before increasing the dose of
thyroxine.

4- Folate antagonists

5- Aminoglycosides

Answer & Comments

Answer: 2- Cephalosporins

Penicillins, cephalosporins (cefuroxime) and
clindamycin are most commonly associated
with pseudomembranous colitis.

[ Q: 2209 ] MRCPass - 2011 May

A 24 year old lady was complaining
of tremors and sw eating for 6 weeks and
referred for assessment.

She has lost 6 kg in weight. A nuclear medicine
scan of the neck showed increased and patchy
uptake of radio isotope of the thyroid glands.
Following tests, she is diagnosed with
thyrotoxicosis and she was started on
thyroxine replacement. 2 months later, she
had blood tests which showed the following
results: free T4- 11 (10-24) pmol/l, TSH 8 (0.3-
4) mU/l.

What should be done next?

1- T3 replacement

2- Check compliance of patient

3- Check thyroid hormone resistance

4- Check pituitary hormone profile

5- Repeat radioisotope scan

[ Q: 2210 ] MRCPass - 2011 May

A 71 year old man who is a heavy
smoker has been brought into hospital, with a
history of cough and breathlessness. He has a
history of COPD which has been managed with
home nebulisers but not oxygen. He was given
60% oxygen by the ambulance crew . He
appears confused when he was brought into
hospital. GCS is 14/15. An arterial blood gas
shows:

pH-7.21 (7.36-7.44)
p02 -18 (11.0-13.5) kPa
pC02 -10 (4.6-6.0) kPa
What should be done?

1- Stop oxygen

2- Give 24% oxygen

3- Continue 60% oxygen

4- Non invasive ventilation

5- Intubation and ventilation

Answer & Comments

Answer: 2- Give 24% oxygen

The best answers here are either give 24%
oxygen or non invasive ventilation.

If the patient is not too unwell and is alert, it is
safe to turn down the oxygen to 24% (1 L) and
assess the degree of hypoxia and C02
retention. With steroids and salbutamol
nebulisers, the patient may improve and not
require NIV. A 02 of 18 is too high for a

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patient with COPD, and when patients are
admitted oxygen therapy should be delivered
to achieve a 02 of about 8-10 on the blood
gas.

[ Q: 2211 ] MRCPass - 2011 May

A set of parents comes to seek
genetic advice at the clinic. They said that
their 5-year-old boy has cystic fibrosis but they
themselves do not have the disease. They also
have a daughter who is 17 years old but not
affected by the disease.

What is the chance that she will be a carrier of
the cystic fibrosis gene?

1- 1 in 2

2- 1 in 4

3- 2 in 3

4- 1 in 25

5- 100% chance

Answer & Comments

Answer: 3- 2 in 3

Inheritance of cystic fibrosis is autosomal
recessive.

In answering this question, the simple mistake
is to take carriers out of total, which makes a 1
in 2 chance. The diagram below illustrates the
best way of working this out.

As the sister is not affected, there are 3 other
options, so she might be a carrier in 2 of the 3
scenarios (2 in 3).

Unaffected

CF carrier

CF sufferer

[ Q: 2212 ] MRCPass - 2011 May

A 31 year old female patient seeks
medical help for infertility and has
subsequently been diagnosed as having
polycystic ovarian disease on ultrasound.

Which one of the features is likely to be
present?

1- Low androgen levels

2- Weight loss

3- Alopecia

4- Decreased visual acuity

5- Increased insulin resistance

Answer & Comments

Answer: 5- Increased insulin resistance

Common symptoms of Polycystic ovary
syndrome (PCOS) include:

Menstrual disorders - oligomenorrhea or
amenorrhea

Infertility,-generally resulting from chronic
anovulation

Hirsutism and symptoms of
hyperandrogenism, such as acne

Metabolic syndrome- characterised by central
obesity, insulin resistance and other
symptoms.

Metformin is being used increasingly in
polycystic ovary syndrome (PCOS) and non¬
alcoholic steatohepatitis, two diseases that
feature insulin resistance.

Metformin improves insulin sensitivity by
increasing peripheral glucose uptake and
utilization.

[ Q: 2213 ] MRCPass - 2011 May

A 26-year-old man presented with
bi- temporal hemianopia. He mentioned that
his shoe sizes were above that of his friends

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since childhood and he often had sw eaty
episodes.

Which one of the following tests is likely to
confirm the diagnosis of acromegaly?

1- Random growth hormone

2- IGF-1

3- Glucose tolerance test with growth
hormone suppression

4- Synacthen test

5- MRI pituitary

Answer & Comments

Answer: 3- Glucose tolerance test with growth
hormone suppression

In Acromegaly, there is excess Growth
hormone (GH) which is difficult to suppress.

[ Q: 2214 ] MRCPass - 2011 May

A 76-year-old male presented with a
4-year history of mild cognitive decline. He has
a 10-year history of hypertension and type 2
diabetes. According to his family, he had
become more forgetful, yet he was able to
carry out simple tasks independently.. His
short-term memory was impaired, as was his
ability to concentrate. His gait was slow and
he was unsteadyHe leaned backward when he

walked and fell often, especially when trying
to turn to the left or right. He experienced
urinary frequency, nocturia, and urinary
incontinence at least once a

day.

What is the most likely diagnosis?

1- Alzheimer's disease

2- Transient ischaemic attack

3- Lewy body dementia

4- Pick's disease

5- Normal pressure hydrocephalus

Answer & Comments

Answer: 5- Normal pressure hydrocephalus

Normal pressure hydrocephalus (NPH) is a
clinical symptom complex characterized by
abnormal gait, urinary incontinence, and
dementia.

The CT scan often shows evidence of
hydrocephalus (distended ventricles), but the
CSF pressure is normal on lumbar puncture.
The treatment is to remove CSF by lumbar
puncture (normally 50 mis).

[ Q: 2215 ] MRCPass - 2011 May

A 25 year old man is investigated for
infertility. He also had a history of delayed
pubertal development. Physical examination
revealed a slim tall man. There was testicular
atrophy bilaterally and also gynaecomastia.
There was also sparse body hair.

What test is likely to reveal the diagnosis?

1- Polymerase chain reaction

2- Southern Blotting

3- Chromosomal analysis

4- ELISA

5- VDRL

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Answer & Comments

Answer: 3- Chromosomal analysis

Klinefelter's syndrome (XXY) causes testicular
atrophy, which commonly leads to
gynecomastia and infertility.

Diagnosis is by chromosomal analysis (shown
below).

Androgen deficiency causes eunuchoid body
proportions;

sparse or absent, facial, axillary, pubic, or
body hair; decreased muscle mass and
strength; feminine distribution of adipose
tissue; gynecomastia; small testes and penis.

Androgen therapy is the most important
aspect of treatment. Testosterone
replacement should begin at puberty to
correct androgen deficiency

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[ Q: 2216 ] MRCPass - 2011 May

A 65-year-old woman presented
with a history of painful, red left eye for 3
months. The patient's past medical history
includes rheumatoid arthritis, atrial fibrillation
and diabetes. She has arthritis involving both
the knee joints and hands but symptoms are
well controlled at present.

On examination, visual acuities were 6/9 on
the right and 6/60 on the left eye. Slit lamp
examination of the right eye showed a
sectoral nodular changes superotemporally on

the left. There were trace cells in the anterior
chambers of both the eyes. Dilated fundus
examination of both the eyes showed clear
vitreous, cup disc ratio of 0.3 bilaterally and
no retinal lesions were noted.

What is the diagnosis?

1- Scleritis

2- Conjunctivitis

3- Acute closed angle glaucoma

4- Uveitis

5- Iritis

Answer & Comments

Answer: 1- Scleritis

The two principal eye manifestations in
rheumatoid arthritis are episcleritis, which is
usually mild and transient, and scleritis, which
involves the deeper layers of the eye and is a
more serious inflammatory condition.

Rheumatoid Scleritis is most common in the
sixth decade of life, affects women more
frequently than men, and is often bilateral.

Although it maybe an initial sign of
rheumatoid disease it typically presents many
years after the onset of RA and often at the
time when joint inflammation is in remission.
Scleritis typically causes redness, pain (unlike
episcleritis) and loss of vision.

Scleritis

[ Q: 2217 ] MRCPass - 2011 May
A 56 year man complained of tremor

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which was more severe on right. The tremor
persisted while he was moving. There was
mild head nodding. On examination, cranial
nerves were normal. He has normal tone,
power and reflexes in the upper and lower
limbs.

Whot is the treatment of choice?

1- Tetrabenazine

2- Benzhexol

3- Co-careldopa

4- Propranolol

5- Ropinorole

Answer & Comments

Answer: 4- Propranolol

The features of Benign essential tremor are:

aggravation by posture and movement, relief
by rest and alcohol (improvement lasting
about two hours), most affected are the arms,
head and vocal apparatus.

oedema. There was tenderness over the
upper lumbar region.

Blood tests showed:

Hb 10.5 g/dl, WCC 7 x 10 9 /l, platelets 220 x
10 9 /l, sodium 135 mmol/I, potassium 4.2
mmol/l, urea 16 mmol/l, creatinine 220
|imol/l, ALT 22 (5-35) U/l, Bilirubin 13(1-22)
|imol/l, Albumin 32 (37-49) g/l, calcium 2.8
(2.25-2.7) mmol/l, phosphate 0.70 (0.8-8)
pmol/l.

Routine urine examination showed urine
albumin trace, urine protein/creatinine ratio
2.7 and urinary Bence Jones protein was
positive.

What test should be carried out to confirm the
diagnosis?

1- Bone marrow aspiration

2- Plasma electrophoresis

3- MRI of the spine

4- Renal ultrasound

5- Blood film

There is often no rigidity, no cerebellar signs,
it is a familial condition.

Management options include: Blockers -
including propranolol, atenolol and sotalol

primidone

topiramate

botulinum A toxin-haemagglutinin complex

[ Q: 2218 ] MRCPass - 2011 May

A 57 years old woman was admitted
with complaints of anorexia, nausea and
episodic vomiting for last 2 months, decreased
urine output for last 15 days and sw elling of
feet, face and upper limbs for last 15 days. She
had history of fall 12 months back after which
she sustained mild compression fracture of LI
vertebra. After the fall, she has had persistent
backaches. On examination, she was pale, BP
was 160/90 mmHg and bilateral pedal

Answer & Comments

Answer: 1- Bone marrow aspiration

The pathological fractures, renal impairment
and hypercalcaemia point tow ards multiple
myeloma.

The best answers are either plasma
electrophoresis or bone marrow aspiration.
Serum electrophoresis is better as a screening
tool and bone marrow aspirate and biopsy
samples to calculate the percent of plasma
cells in the aspirate (reference range, <3%) will
be the most diagnostic test.

^ [ Q: 2219 ] MRCPass - 2011 May

* ^ j Which one of the following enzymes
is inhibited by alpha 1 antitrypsin?

1- Neutral alpha glucosidase

2- Peroxisome catalase

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3- Lymphocyte 5 neucleotidase

4- Lactate dehydrogenase

5- Neutrophil elastase

Answer & Comments

Answer: 5- Neutrophil elastase

discharged with a follow up appointment to
reassess in 2-4 weeks.

A repeat aspiration is recommended if the
patient is still symptomatic after the first
aspiration (for a primary pneumothorax) and <
2.5 I of air was aspirated in the first attempt as
in this case.

Alpha 1-antitrypsin (A1AT) is produced in the
liver, and one of its functions is to protect the
lungs from the neutrophil elastase enzyme,
which can disrupt connective tissue.

Smokers develop increased levels of elastase
enzymes and thus are more at risk of
emphysema in alpha 1 antitrypsin deficiency.

[ Q: 2220 ] MRCPass - 2011 May

A 44 year old man is referred to the
hospital by the GP as he had a routine chest x
ray which was abnormal. The patient does not
complain of any symptoms. He is a non
smoker and has no previous medical history of
respiratory problems. His BP was 110/80 &
pulse was 80/min. CXR shows a pneumothorax
with a 1.5 cm diameter rim of air from the
chest wall.

Which is the most appropriate step?

1- Chest drain

2- Oxygen therapy

3- Observation and follow up

4- Needle aspiration

5- VATs procedure

Answer & Comments

Answer: 3- Observation and follow up

This patient has a asymptomatic primary
pneumothorax.

BTS Pneumothorax 2010 Guideline.

[ Q: 2221 ] MRCPass - 2011 May

A 26-year-old left-handed woman
was referred for evaluation of pain in the left
wrist. 6 months previously, she started to
develop numbness involving the lateral three
digits of the left hand and pain in the left
wrist. There was weakness of thumb
abduction and mild wasting of the thenar
muscles. Muscle stretch reflexes were normal.

Sensation to pinprick was diminished on the
volar surface of the second and third digits of
the left hand. On her left side, Phalen's sign
was present, and Tinel's sign was elicited over
the median nerve at the wrist.

What is the likely diagnosis?

1- Brachial plexus neuropathy

2- Ulnar nerve neuropathy

3- Radial nerve neuropathy

4- Axillary nerve neuropathy

5- Carpal tunnel syndrome

Answer & Comments

Answer: 5- Carpal tunnel syndrome

Carpal tunnel syndrome occurs when the
median nerve is compressed at the wrist,
leading to pain, paresthesia, and muscle
weakness in the forearm and hand.

The latest BTS guidelines (2010) continues to
distinguish between a large and small
pneumothorax as defined by a rim of > 2cm or
< 2 cm from the chest wall. For patients who
are asymptomatic, the patient can be

There may be loss of sensation to the area of
the thumb, index, middle, and radial half of
the ring finger motor wasting and weakness
lead to thenar wasting and weakened
abduction of the thumb

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Phalen's test is used in carpal tunnel
syndrome where forcible palmar flexion of the
wrist causes venous engorgement of the canal
and an exacerbation of the symptoms. Tinel's
test is performed by tapping over the carpal
tunnel, it causes tingling in the thumb and
radial two and a half fingers.

Tinel's test

[ Q: 2222 ] MRCPass - 2011 May

A 61 year old man is unwell having
ingested a bottle of dye. On examination, he is
afebrile but has tachypnea, cyanosis, and
drow siness. He is given 100% oxygen but does
not improve. A lab test confirms
methaemoglobin levels >70% hence
confirming the diagnosis. In
methaemoglobinaemia, what is the underlying
mechanism?

1- Reductive stress

2- Oxidation of Fe2+ to Fe3+

3- Increase in NADP levels

4- Increase in NADPH levels

5- Increase in gluthathione system

Answer & Comments

Answer: 2- Oxidation of Fe2+ to Fe3+

Methaemoglobinaemia is haemoglobin with
an oxidised ferric state Fe3+ instead of the
ferrous state Fe2+.

It is commonly due to oxidative stress, caused
by drugs or exogenous substances e.g.
sulphonamides, trimethoprim or dyes,
chlorates, bromates, nitrates (fertilisers). It
causes cyanosis when metHb >1.5 g/dl.
Chemicals which are oxidising agents may
cause this e.g. aniline dyes, chlorates, nitrates,
nitrophenols, primaquine and sulphonamides.

Treatment is with methylene blue if
methaemoglobin >3.0g/dL.

Mechanisms to counteract oxidative stress:
NADH methemoglobin reductase

(cytochrome-b5 reductase) (major pathw ay),
NADPH methemoglobin reductase (minor
pathw ay), the ascorbic acid and glutathione
enzyme systems are usually overw helmed.

[ Q: 2223 ] MRCPass - 2011 May

A 31 year old man presents with
fevers, malaise and a cough. There was
associated lethargy. He is a type 1 diabetic and
is on insulin. He works in a water purifier
factory, and legionella infection is suspected.

Which of the following tests is most practical
for confirming the diagnosis?

1- Serum Immuno Fluorescent Antibody

2- Sputum Immuno Fluorescent Antibody

3- Sputum microscopy and culture

4- Urinary antigen

5- PCR for legionella DNA

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Answer & Comments

Answer: 4- Urinary antigen

The urine antigen test is a rapid, relatively
inexpensive, and practical test for the
detection of Legionella

pneumophila antigen excreted in the urine or
present in pleural fluid.

Direct fluorescent antibody (DFA) staining is a

rapid test that can be performed on
respiratory samples and tissue and requires
only 2-4 hours for results. It is

very specific but not sensitive, hence a
negative result does not rule out legionella
infection.

[ Q: 2224 ] MRCPass - 2011 May

A 26 year old nurse has known latex
allergy and currently avoids using latex gloves
at work. One day after

This is because some of the proteins in latex
show cross-reactivity, perhaps

because of resemblance to a latex protein
component.

[ Q: 2225 ] MRCPass - 2011 May

A 30-year-old man who has returned
from a holiday in Egypt presents with
diarrhoea. He had been on a cruise at the Nile
river. For the past two days he has been
passing frequent bloody diarrhoea associated
with crampy abdominal pain. Abdominal
examination demonstrates diffuse lower
abdominal tenderness but there is no
guarding or rigidity. His temperature is 37.8°C.

What is the most likely causative organism?

1- Giardiasis

2- Enterotoxigenic Escherichia coli

3- Staphylococcus aureus

4- Shigella

lunch, she developed itching and flushing to
her face with difficulty in breathing. She
mentioned that she only had

a salad and some fruit.

Which fruit is most likely to be associated with
latex allergy?

1- Banana

2- Orange

3- Apple

4- Pear

5- Salmonella

Answer & Comments

Answer: 4- Shigella

All are common causes of traveller's
diarrhoea.

However, North Africa and the Middle East (in
particular Egypt) were also commonly
reported regions of travel for Shigella spp
infections.

5- Grape

Answer & Comments

Answer: 1- Banana

Some people with latex allergy have allergic
reactions when eating particular foods
including banana, avocado,

chestnut, tomato, peach or kiw ifruit.

Some of the infectious causes of bloody
diarrhoea are:

■ Salmonella

■ Shigella

■ Campylobacter jejuni

■ Yersinia enterocolitica

■ E. coli

Entamoeba histolytica

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[ Q: 2226 ] MRCPass - 2011 May

A 25 year old man was admitted to
the with the complaints of generalised
weakness of whole body. Upon further
enquiry, he described easily being tired,
difficulty with his speech and drooping of both
the eyelids for the past 6 months. All his
symptoms are worse on exertion and in the
evening. He mentioned that in the evenings
he occasionally developed double vision. He
does not have any past medical history and
does not take regular medication. On
examination he has a BP of 120/70 mmHg and
02 saturations of 99% on air. He had bilateral
ptosis, reduced power in all the muscles of the
four limbs with normal reflexes, bilateral
flexor planters and normal sensation.

What is the likely diagnosis?

1- Motor neuron disease

2- Multiple sclerosis

3- Myasthenia gravis

4- Paraneoplastic syndrome

5- Parkinson's syndrome

Answer & Comments

Answer: 3- Myasthenia gravis

Myasthenia Gravis is an autoimmune
neuromuscular disease leading to fluctuating
muscle weakness and fatiguability.

It is an autoimmune disorder, in which
weakness is caused by circulating antibodies
that block acetylcholine receptors at the
postsynaptic neuromuscular junction.

directly improve muscle function and
immunosuppressant (prednisone, cyclosporin,
mycophenolate and azathioprine.

Thymectomy is essential in cases of suspected
thymoma in view of the potential neoplastic
effects of the tumor.

[ Q: 2227 ] MRCPass - 2011 May

A 76 year-old female was seen in the
Emergency department with a 2 day history of
headaches and fever. On examination, the
patient had a temperature of 38.5 °C. There
was also evidence of meningism with a
positive Kernig's sign. Tone, power and
reflexes were normal apart from general
weakness. There was no sensory deficit. A
lumbar puncture was performed. CSF showed
100 white cells (90% lymphocytes), protein 0.9
(<0.5) and glucose 3.3, plasma glucose 7.5.
The patient was commenced on rifampicin,
isoniazid, pyrazinamide and ethambutol.

What other drug should be added?

1- Fusidic acid

2- Streptomycin

3- Prednisolone

4- Linezolid

5- Rituximab

Answer & Comments

Answer: 3- Prednisolone

In Tuberculous meningitis, Fever, headache,
confusion and meningism are presenting
features.

The classic feature of myasthenia gravis is
fatiguability. Muscles become progressively
weaker during periods of activity and improve
after periods of rest. Muscles that control
ocular movements, facial expression, chewing,
talking, and sw allowing are affected. Ptosis
and diplopia are common presentations.

Medication consists mainly of cholinesterase
inhibitors (neostigmine, pyridostigmine) to

The CSF usually has a high protein, low glucose
and a raised number of lymphocytes as seen
in this patient.

Acid-fast bacilli are sometimes seen on a CSF
smear, but more commonly, M. tuberculosis is
grown in culture.

Quadruple Tuberculous therapy is
recommended in cases of pulmonary TB, but

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for TB meningitis, prednisolone is added and
treatment is continued for at least 1 year.

Answer & Comments

Answer: 2- 50% of all children

[ Q: 2228 ] MRCPass - 2011 May

A patient who is on haemodialysis is
on several medications.

Which one of the following is the most likely
reason for a drug to be ineffectively removed
by dialysis?

1- High water solubility

2- High first pass metabolism

3- High plasma protein binding

4- High volume of distribution

5- Low bioavailability

Answer & Comments

Answer: 3- High plasma protein binding

Because the primary binding proteins for most
drugs (albumin, ?l-acid glycoprotein) are of
large molecular size, the drug-protein complex
is often unable to cross the dialysis
membrane, especially the hemodialysis
membrane.

Drugs that are highly protein-bound (e.g.,
phenytoin, valproate) are difficult to remove
from the systemic circulation by hemodialysis.

[ Q: 2229 ] MRCPass - 2011 May

A couple presents to the clinic for
genetic counselling. The male partner has
haemophilia whilst the female partner has
been screened and shown to be a carrier of
the gene causing haemophilia A.

What is the chance that a child would have
haemophilia?

1- 25% if male child, 0% if female child

2- 50% of all children

3- 100% if male child, 0% if female child

4- 50% if male child, 0% if female child

5- 25% of all children

Hemophilia A is X linked recessive, which
means that females are commonly carriers
and males are affected if they inherit the
affected X chromosome.

In this case, if the affected X chromosome is
designated Xa, the father is XaY and mother
XaX. The children would be either XaXa, XaX,
XaY and XY. In this situation 50% (XaXa and
XaY) of all children will be affected. It would
also be 50% of male children, and 50% of
female children affected (refer to top half of
diagram below).

Father Children

hemophiliac

[ Q: 2230 ] MRCPass - 2011 May

A 25 year old patient has been
diagnosed with adult polycystic kidney disease
recently. The family came to the clinic for
advice. In particular, his brother and sister
would like to know the likelihood of them
developing the disease.

Which one of the following is the most
appropriate screening test?

1- Renal ultrasound of the brother and sister

2- Renal ultrasound scan of all first degree
relatives

3- Renal MR angiography of brother and sister

4- Renal MR angiography of all first degree
relatives

5- Renal function test for all first degree
relatives

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Answer & Comments

Answer: 2- Renal ultrasound scan of all first
degree relatives

Although the brother and sister are
enthusiastic for screening, the whole family
(anyone aged >20) should be screened with
ultrasound.

[ Q: 2231 ] MRCPass - 2011 May

An 80 year old lady undergoes
preoperative assessment for colorectal
surgery but is found to be unwell. She is on
analgesic medications only. On examination,
she looks pale and there is evidence of vitiligo.
A spleen was palpable at 2 finger breadths
below the costal margin. Investigation of
blood results showed:

Hb 7.5 g/dl

MCV 106 fl

WCC 3 x 10 9 /l

platelets 85 x 10 9 /l

sodium 138 mmol/I

potassium 4.5 mmol/l

urea 6 mmol/l

creatinine 68 |imol/l

ALT 30 (5-35) U/l

ALP 110 (20-120) U/l

Bilirubin 35 (1-22) |imol/l

Lactate dehydrogenase 550. (110-230) U/L

What is the diagnosis?

1- Pernicious anaemia

2- Myelodysplasia

3- Autoimmune haemolytic anaemia

4- Chronic myeloid leukaemia

5- Polycythaemia rubra vera

Answer & Comments

Answer: 1- Pernicious anaemia

Pernicious anaemia is usually associated with
atrophic gastritis, the autoimmune
destruction of gastric parietal cells leads to a
lack of intrinsic factor.

Typically, patients with pernicious anemia are
described as having a stereotypic appearance.
Patients have a lemon-yellow waxy pallor with
premature whitening of the hair. A splenic tip
is palpable in about 20% of patients. Vitiligo
which was seen here is an autoimmune
disorder which may be associated with other
autoimmune diseases, such as pernicious
anemia, rheumatoid arthritis, type 1 diabetes,
alopecia areata, and diseases of the thyroid
gland.

In pernicious anaemia, the peripheral blood
usually shows a macrocytic anemia with a mild
leukopenia and thrombocytopenia. The mean
cell volume (MCV) and mean cell hemoglobin
(MCH) are increased. The bilirubin level may
be elevated because pernicious anemia is a
hemolytic disorder associated with increased
turnover of bilirubin.

The serum lactic dehydrogenase (LDH)
concentration usually is markedly increased.

[ Q: 2232 ] MRCPass - 2011 May

A 75 year old man has palpitations
and is admitted to hospital. He has a past
medical history of previous myocardial
infarction and hypertension. An ECG shows
atrial fibrillation and he was monitored on the
ward. The next day, the ECG was repeated and
it showed sinus rhythm.

Which of the following should be started for
maintenance of sinus rhythm?

1- Digoxin

2- Flecainide

3- Amlodipine

4- Sotalol

5- Ramipril

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Answer & Comments

Answer: 4- Sotalol

Flecainide is a class Ic antiarrhythmic (sodium
channel blocker) which is useful for
paroxysmal AF.

However, the CAST trial showed that patients
who had ischaemic heart disease had a worse
outcome when treated with flecainide, so it is
generally not used in patients with established
history of ischemic heart disease. Other
helpful options to maintain sinus rhythm are
beta blockers (sotalol) and amiodarone. In this
scenario sotalol is the best option.

[ Q: 2233 ] MRCPass - 2011 May

A drug which has been on the
market for 2 years, has had reports of possible
serious side effects of fulminant hepatitis.

Whot is the best way of evaluate this from a
safety perspective?

1- Metanalysis

2- Postmarketing surveillance

3- Randomised controlled trial

4- Systematic review

5- Case control study

Answer & Comments

Answer: 2- Postmarketing surveillance

[ Q: 2234 ] MRCPass - 2011 May

A 53 year man enquired about
whether it was advisable to have vaccination
prior a holiday abroad. He had treated asthma
and had been on long term steroids regularly.

Which one of the following is a live vaccine
which should be used with caution in this
man?

1- Yellow fever

2- Diphtheria toxoid

3- Hepatitis B

4- Meningococcus

5- Tetanus toxoid

Answer & Comments

Answer: 1- Yellow fever
The live vaccines are:

■ BCG

■ Mumps

■ Measles

■ Rubella

■ Yellow fever
Smallpox

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^ [ Q: 2235 ] MRCPass - 2011 May

0 In the cell cycle, which phase does
chromotin condense into chromosomes?

1- Prophase

2- Metaphase

3- Anaphase

4- Telophase

5- Cytokinesis

Answer & Comments

Answer: 1- Prophase

The relatively brief M phase consists of
nuclear division (karyokinesis).

The M phase has been broken down into
several distinct phases, sequentially known as:

Prophase, metaphase, anaphase, telophase,
cytokinesis.

Prophase, is a stage of mitosis in which the
chromatin condenses (it becomes shorter and
fatter) into a highly ordered structure called a
chromosome in which the chromatin becomes
visible.

Nuclear Plasma Chromosome, consisting
envelope membrane of two sister chromatids

G 2 OF INTERPHASE

Centrosomes Chromatin

(with centriole pairs) (duplicated)

PROPHASE
Early mitotic

PROMETAPHASE

Kinetochore

microtubule

METAPHASE

ANAPHASE

TELOPHASE AND CYTOKINESIS

Meta phase
plate

Cleavage

Nucleolus

Daughter

chromosomes

envelope

forming

[ Q: 2236 ] MRCPass - 2011 May

A 76 year old white male with a past
I history of duodenal ulcers presents to
the emergency department complaining of

medica

nausea, vomiting, flushing, diarrhea and a dry
cough for two months. The patient stated the
pain did not change with food or position and
was not accompanied by any fevers, chills,
jaundice, diarrhea or blood per rectum. The
patient's social history included occasional
alcohol and tobacco use. On examination,
there was hepatomegaly. Carcinoid syndrome
was suspected. Investigations showed that a
24 hour urine collection for 5-
hydroxyindoleacetic acid was dramatically
elevated at 400 milligrams. An octreotide scan
revealed increased uptake in the lung
confirming the diagnosis of a carcinoid lung
tumor.

Which one of the following is the most early
symptom in carcinoid syndrome?

1- Diarrhoea

2- Facial flushing

3- Vomiting

4- Haemoptysis

5- Nausea

Answer & Comments

Answer: 2- Facial flushing

Patients with carcinoids have commonly been
diagnosed with irritable bow el syndrome or
idiopathic flushing.

The syndrome is characterized by
hepatomegaly, diarrhea, and flushing in 80%
of patients; right heart valvular disease in
50%; and asthma in 25%. Cutaneous flushing
is a common manifestation (~80% of patients)
and is often the earliest sign of the syndrome.
Flushing can occur spontaneously, typically in
the head and neck. It may be triggered by
excitement, exercise, some types of food, or
alcohol. Flushing is mediated by the
vasoactive peptides secreted by the tumor.
Diarrhea is also very common.

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[ Q: 2237 ] MRCPass - 2011 May

A 41 year old lady presents with a 1
year history of pain in the right hand
progressing to involve the entire right upper
limb up to the scapular and pectoral regions.
On examination, there is decreased pinprick
and temperature sensation in the hand. There
were absent biceps and supinator reflexes and
there is muscle wasting in the forearm.

The likely diagnosis is:

1- Brachial plexus infiltration

2- Cervical spondylosis

3- Syringomyelia

4- Subacute combined degeneration of the
cord

5- Motor neuron disea

Answer & Comments

Answer: 3- Syringomyelia

12 days earlier and persisted despite
treatment with oral antibiotics and anti¬
inflammatory drugs. The fever episodes
occurred every 48 hours, with high peaks
followed by abrupt resolution. He had just
returned from India a month ago, and had not
received any anti-malarial prophylaxis a.

What is the best antimalarial treatment?

1- Quinine

2- Chloroquine

3- Mefloquine

4- Pyrimethamine and sulphadiazine

5- Artesunate

The clinical features are consistent with
syringomyelia.

Syringomyelia is a chronic disorder
characterized by the presence of a
longitudinal, fluid filled cavities (syrinx) within
the spinal cord. Syrinx interrupts the
decussating spinothalamic fibers that mediate
pain and temperature. When the cavity
enlarges to involve the posterior columns,
position and vibration senses in the feet are
lost (hence positive Rombergs). Syrinx
extension into the anterior horns of the spinal
cord damages motor neurons (lower motor
neuron) and causes diffuse muscle atrophy
that begins in the hands and progresses
proximally to include the forearms and
shoulder girdles. Impaired bowel and bladder
functions usually occur as a late manifestation
of autonomic problems.

[ Q: 2238 ] MRCPass - 2011 May

A 56-year-old man presented
because of a fever (up to 40°C) that had begun

Answer & Comments

Answer: 2- Chloroquine

Plasmodium vivax is found mainly in Asia,
Latin America, and in some parts of Africa.

^ [ Q: 2239 ] MRCPass - 2011 May

mil

* A 48 year old patient had chest pain.
His ECG showed ST elevation in the leads II, III,
aVF and he also had no correlation between p
waves and QRS complexes.

Which artery is likely to be affected?

1- Left main stem

2- Left anterior descending

3- Circumflex

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4- Right coronary artery

5- Diagonal

The clues for Behcet's disease here are oro-
genital ulceration, eye involvement, Turkish
origin and also erythema nodosum.

Answer & Comments

Answer: 4- Right coronary artery

The diagnosis is an inferior myocardial
infarction with complete heart block, this is
most commonly due to a RCA lesion.

Inferior Ml (sinus rhythm)

[ Q: 2240 ] MRCPass - 2011 May

A 34 year old white Turkish woman
presented with a swollen left leg which was
painful.

She has a history of conjunctivitis, joint pains,
oral and genital ulceration and livedo
reticularis.

On presentation she was afebrile, with
cervical lymphadenopathy. The patient was
noted to have oral ulcers and a genital ulcer.
She had a rash on both her legs. The leg on
the left was erythematous, painful and tender
to compression.

What is the likely diagnosis?

1- Wegener's granulomatosis

2- Henoch Schonlein purpura

3- Behcet's disease

4- Non Hodgkin's lymphoma

5- Kawasaki's disease

Answer & Comments

Answer: 3- Behcet's disease

The usual presentation in Behcet's disease is
of mouth ulcers, sore genitals and eye
inflammation, and arthritis in older patients.

Patients must have must have mouth ulcers
(any shape, size or number at least 3 times in
any 12 months), and 2 out of the next 4
"hallmark" symptoms:

- genital ulcers (including anal ulcers and spots
in the genital region and swollen testicles or
epididymitis in men), -skin lesions (papulo¬
pustules, folliculitis, erythema nodosum, acne
in post-adolescents not on corticosteroids)

- eye inflammation (iritis, uveitis, retinal
vasculitis, cells in the vitreous), pathergy
reaction (papule >2 mm dia. 24-48 hrs or more
after needle-prick).

There is an increased thrombotic tendency
among Behcet's disease patients, in this case
the patient has a clinical presentation
consistent with a deep vein thrombosis in the
leg.

Oral Ulceration in Behcets

[ Q: 2241 ] MRCPass - 2011 May

An 81-year-old man with a history of
schizoaffective disorder presented to hospital
with increasing auditory hallucinations,
persecutory delusions and depressive
symptoms, including suicidal ideation. He was
admitted to hospital and given haloperidol for
his psychotic symptoms.

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Three days later he became mildly confused.
His temperature was elevated (38.3°C), and
although normotensive (blood pressure
124/84 mm Hg) he had tachycardia (heart rate
128 beats/min) and exhibited Parkinsonian
signs.

Which one of the following suggests
neuroleptic malignant syndrome?

1- Muscular rigidity

2- Visual blurring

3- Diarrhoea

4- Constipation

5- Erythematous rash

Answer & Comments

Answer: 1- Muscular rigidity

Neuroleptic malignant syndrome (NMS) refers
to the combination of hyperthermia, rigidity,
and autonomic dysregulation (labile blood
pressure) that can occur as a serious
complication of the use of antipsychotic drugs.

The most widely accepted mechanism by
which antipsychotics cause NMS is that of
dopamine D2 receptor antagonism.

This leads to increased muscle rigidity and
tremor via extrapyramidal pathw ays.

[ Q: 2242 ] MRCPass - 2011 May

Within which part of the nephron
does the anti diuretic hormone work on?

1- Proximal convoluted tubule

2- Descending limb Loop of Henle

3- Ascending limb Loop of Henle

4- Distal convoluted tubule

5- Cortical collecting duct

Answer & Comments

Answer: 5- Cortical collecting duct

Though the collecting duct particularly the
outer medullary and cortical collecting ducts
are normally impermeable to water, but they
becomes permeable under the actions of
antidiuretic hormone (ADH).

As much as three-fourths of the water from
urine can be reabsorbed as it leaves the
collecting duct by osmosis.

Proximal

convoluted

tubule t Bowman's

capsule

Distal

convoluted

tubule

Glomerulus

Cortex

Medulla

Loop of Henle

Collecting

tubule

to ureter

[ Q: 2243 ] MRCPass - 2011 May

A 70-year-old woman presented to
the emergency room with an acute history of
progressive exertional chest pain. The pain
was sharp and was associated with shortness
of breath. Physical activity made it worse and
improvement was noted with sublingual
nitroglycerin. On arrival to the department her
blood pressure was 105/62 mmHg, pulse was
98 beats per minute. Cardiac examination
revealed a regular heart with no murmur, rubs
or gallop. The ECG showed sinus rhythm with
low voltage, left axis deviation with ST, lateral
T wave abnormalities and elevated cardiac
enzymes Her Troponin T levels peaked at
5ng/ml (< O.lOng/ml). The following day, her
chest pains subsided but she developed
fevers, myalgia and a mottled discoloration of
both her legs.

What other finding is likely?

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1- Anaemia

2- Polycythaemia

3- Thrombocytopenia

4- Eosinophilia

5- Haemolysis

Answer & Comments

Answer: 4- Eosinophilia

This patient had a myocardial infarction and
has developed cholesterol emboli probably
due to severe atherosclerosis of the aorta.

The symptoms experienced in cholesterol
embolism are fever, muscle ache and weight
loss. Embolism to the legs causes a mottled
appearance and purple discoloration of the
toes, small infarcts and areas of gangrene due
to tissue death that usually appear black, and
areas of the skin that assume a marbled
pattern known as livedo reticularis. The full
blood count may show particularly high
numbers eosinophils (more than 0.5 x 10 9 /l);
this occurs in 60-80% of cases.

[ Q: 2244 ] MRCPass - 2011 May

A 26-year-old presents with a six
weeks history of galactorrhoea. She has no
other symptoms but takes medication for
contraception, indigestion and headaches. She
was found to have a Prolactin level of 850
mU/L (< 450).

Which one of the following drugs may be
responsible?

1- Codeine phosphate

2- Metoclopramide

3- Omeprazole

4- Oral contraceptive pill

5- Sumatriptan

Answer & Comments

Answer: 2- Metoclopramide

Metoclopramide acts as a dopamine
antagonist.

Dopamine inhibits the release of Prolactin
from the anterior Pituitary gland. Therefore,
metoclopramide can predispose to
hyperprolactinaemia, which in turn causes
galactorrhoea.

^ [ Q: 2245 ] MRCPass - 2011 May

# A 46 year old lady presented to her
GP with lesions in skin that were circular with
an erythematous raised rim with central
atrophy. There was scaliness, follicular
plugging, and telangiectasia over the scalp,
ears and face.

This was confirmed to be discoid lupus by the
dermatologist and she has been tried on
betnovate steroid topical treatment but has
not improved.

What should be used next?

1- Diprobase cream

2- Tacrolimus

3- Azathioprine

4- Hydroxychloroquine

5- PUVA therapy

Answer & Comments

Answer: 4- Hydroxychloroquine

Discoid lupus erythematosus (DLE) is a
chronic, scarring, atrophy producing,
photosensitive dermatosis.

DLE may occur in patients with systemic lupus
erythematosus (SLE).

Initial treatment comprises the avoidance of
direct sunlight. Following this,
Hydroxychloroquine is the gold standard
treatment. Other options include
azathioprine, dapsone, thalidomide and
tacrolimus.

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[ Q: 2246 ] MRCPass - 2011 May

A 41-year-old woman with a past
history of epilepsy complains of recurrent
migraine type headaches. The headaches have
been occurring daily, and are associated with
flashing lights. She was previously treated
with paracetamol, aspirin and diclofenac with
little improvement.

What of the following medications should you
then prescribe?

1- Pizotifen

2- Meperidine

3- Sumatriptan

4- Ergotamine

5- Propranolol

Answer & Comments

Answer: 3- Sumatriptan

Sumatriptan is structurally similar to
serotonin, and is a 5-HT1D agonist, which is
one of the receptors to which serotonin binds.

4- Diabetic nephropathy

5- IgA nephropathy

Answer & Comments

Answer: 2- Reflux nephropathy

Urine reflux is the most common cause of
chronic pyelonephritis and can lead to
nephropathy.

The risk factors include a personal or family
history of reflux. Ultrasound can identify renal
scarring if moderate to severe in degree

[ Q: 2248 ] MRCPass - 2011 May

A 45 year old lady presented to
hospital complaining of lesions on the skin.
The patient is Brazilian and has been in the
country for several months. The skin lesions
were circular with an erythematous raised rim
with central atrophy. There was scaliness,
follicular plugging, and telangiectasia over the
face. There was also evidence of loss of hair
around the eyebrows.

Low serotonin levels in the brain may lead to a
process of constriction and dilation of the
blood vessels which trigger a migraine.
Triptans activate serotonin receptors to stop a
migraine attack, and are recommended for
treating acute migraine headaches. They take
15-30 minutes to work.

What is the diagnosis?

1- Cutaneous leishmaniasis

2- Discoid lupus erythematosus

3- Leprosy

4- Lyme's disease

5- Pityriasis versicolor

^ [ Q: 2247 ] MRCPass - 2011 May

# A 31 year old woman has a history of

recurrent urinary tract infections as a child.
Her mother has a history of hypertension and
was told that her kidneys were 'damaged'. An
ultrasound of the patient showed scarring in
both kidneys.

What is the most likely diagnosis?

1- Autosomal dominant polycystic kidney
disease

2- Reflux nephropathy

3- Renal cell carcinoma

Answer & Comments

Answer: 2- Discoid lupus erythematosus

Discoid lupus erythematosus (DLE) is a
chronic, scarring, atrophy producing,
photosensitive dermatosis.

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moderate scaling. As the lesion progresses,
the scale may thicken and become adherent,
and pigmentary changes may develop, with
hypopigmentation in the central or inactive
area and hyperpigmentation at the active
border. Hydroxychloroquine can be used for
treatment.

The other possible answer here is cutaenous
leishmaniasis. The typical lesions are crusty,
painless ulcers on exposed skin. Ulcerative
lesions are usually shallow and circular with
well-defined, raised borders and a bed of
granulation tissue. However, the eyebrow
alopecia for this patient makes discoid lupus
more likely.

Discoid Lupus

[ Q: 2249 ] MRCPass - 2011 May

A 62 year old man presented with
fevers, lethargy and 2 month history of
malaise. He also mentioned altered bow el
habit. On examination, he had a temperature
of 39 C and a soft systolic murmur in the
mitral area. He also had several splinter
haemorrhages. Blood culture results within 24
hours grew streptococcus bovis.

What investigation will help determine the
underlying source of infection?

1- Abdominal x ray

2- Colonoscopy

3- CT scan of the chest

4- Skin biopsy

5- Transoesophageal echocardiogram

Answer & Comments

Answer: 2- Colonoscopy

A correlation exists between colon cancer and
Strep.

bovis proliferation in the large intestine,
hence predisposing to endocarditis. The
patient needs a colonoscopy which may
identify a colorectal malignancy predisposing
to strep bovis bacteraemia and endocarditis.

[ Q: 2250 ] MRCPass - 2011 May

A 44 year old female patient
presented in to clinic with a generalised
blistering rash on the arms and legs. Clinical
examination revealed tense skin blisters with
some generalised desquamation. There was
no involvement of the mucous membranes.

What is the diagnosis?

1- Pemphigus vulgaris

2- Erythema multiforme

3- Dermatitis herpetiformis

4- Bullous pemphigoid

5- Insect bite

Answer & Comments

Answer: 4- Bullous pemphigoid

Bullous pemphigoid is more common than
pemphigus , occurs more commonly in later
life (>60years).

It is a chronic, autoimmune, subepidermal,
blistering skin disease that rarely involves
mucous membranes. Large bullae appears
anyw here on the skin ,they tend to be itchy
and the lesions are deep and mucosal
involvement rare. Bullous

pemphigoid is characterized by the presence
of immunoglobulin G (IgG) autoantibodies in
the hemidesmosomal area.

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These manifest as tense blisters. Direct
immunofluorescence of a skin biopsy usually
demonstrate IgG and complement C3
deposition in a linear band at the dermal-
epidermal junction.

Bullous Pemphigoid

[ Q: 2251 ] MRCPass - 2011 May

A 35-year-old, female secretary
presents to the emergency department with 7
days of bloody diarrhea and lower abdominal
cramping. A flexible sigmoidoscopy and biopsy
showed evidence of inflammation consistent
with ulcerative colitis. Over the next few
months, she continued to have several
episodes of such presentations which required
steroid treatment.

What should be prescribed now?

1- Infliximab

2- Azathioprine

3- Chlorpromazine

4- Amitriptyline

5- Low dose prednisolone

Answer & Comments

Answer: 2- Azathioprine

Azathioprine may be used in patients with
Crohn's disease or ulcerative colitis that are
steroid dependent or steroid resistant.

This is a very effective, safe and well-tolerated
drug with no definite associated risk of cancer.

Azathioprine has a slow onset of action and
requires continuing steroid cover for 8-12
weeks. The principle side-effects of
azathioprine are idiosyncratic acute
pancreatitis and bone-marrow suppression.

[ Q: 2252 ] MRCPass - 2011 May

A 70-year-old woman has lung
carcinoma and recently underwent
chemotherapy. She presented with shortness
of breath and pleuritic chest pain.

Which one of the following signs suggests a
significant pericardial effusion?

1- Systolic murmur

2- Pericardial rub

3- Rapid y descent of JVP

4- Pulsus paradoxus

5- Pulses alternans

Answer & Comments

Answer: 4- Pulsus paradoxus

The question asks for which signs are present
in cardiac tamponade due to a large
pericardial effusion.

The main signs are Kussmaul's sign (increase in
JVP with inspiration) and Pulsus paradoxus
(the inspiratory fall of aortic systolic pressure
greater than 10 mm Hg).

[ Q: 2253 ] MRCPass - 2011 May

A 58 year old man has presented
with chest pain and pulmonary oedema. He is
managed as acute coronary syndrome. He did
not tolerate a GTN infusion as his blood
pressure was 85/60 but improved with
frusemide and his blood pressure stabilized.
An ACE-inhibitor was held off due to renal
impairment. He is coincidentally found to have
a chest infection, his blood cultures grew

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streptococci and he was treated with
augmentin. His blood tests on admission show
a creatinine of 145 pmol/l rising up to 190
pmol/l and then 250 pmol/l the day after.

What is the likely cause of acute kidney injury?

1- Urinary tract infection

2- Acute tubular necrosis

3- Interstitial nephritis due to augmentin

4- Post streptococcal glomerulonephritis

5- Renal artery stenosis

prolapse. He also had pectus excavatum,
arachnodactyly and arm span greater than
height. Slit lamp examination revealed had
upward dislocation of the lens in the eye.

The gene defect is:

1- Actin

2- Myosin

3- Fibrillin

4- Retinoblastoma

5- Elastin

Answer & Comments

Answer: 2- Acute tubular necrosis

Answer & Comments

Answer: 3- Fibrillin

A rapid rise in creatinine following periods of
hypotension is most commonly due to acute
tubular necrosis.

Acute tubular necrosis or (ATN) involves the
death of tubular cells that form the tubule
that transports urine to the ureters while
reabsorbing 99% of the water. Tubular cells
continually replace themselves and if the
cause of ATN is removed then recovery is
likely.

A renal biopsy shows renal medulla, which is
composed mainly of renal tubules. Patchy or
diffuse denudation of the renal tubular cells is
observed, suggesting acute tubular necrosis

(ATN)

[ Q: 2254 ] MRCPass - 2011 May

A 21 year old man is tall compared to
his peers. On examination, he was found to
have aortic incompetence and mitral valve

The fibrillin gene defect is the basis of
Marfan's syndrome.

It is an autosomal dominant disorder
characterised by arachnodactyly, upward lens
dislocation, tall habitus and flat feet. Aortic
aneurysms and aortic regurgitation are also
associated.

^ [ Q: 2255 ] MRCPass - 2011 May

f -

A 44 year old woman was admitted
to hospital with a several month history of
diarrhoea, malaise and weight loss. She was in
good health prior to the development of these
symptoms. On examination, she had mild
jaundice and looked thin. She had a distended
abdomen with shifting dullness to percussion.
Her blood tests show :

Hb 10.5 g/dl

MCV 82 fl

WCC 8 x 10 9 /l

platelets 220 x 10 9 /l

sodium 125 mmol/l

potassium 4.1 mmol/l

urea 11 mmol/l

creatinine 160 |imol/l

ALT 95 (5-35) U/l

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AST 115 (1-31) U/l
ALP 220(20-120) U/l
Bilirubin 30 (1-22) nmol/l
Albumin 28 (37-49) g/l

Carcinoembryonic antigen (CEA) 3.8 <2.5
ng/ml

Alpha-Fetoprotein (AFP) 55 < 44 ?g/L

CA 125 - 38 (<35) U/m

CA 19.9 - 250 (< 40) U/ml

CA 15.3 - 32 (< 29) U/mL

Prostate-Specific Antigen (PSA) 2 (< 4) ng/ml

Which one of the following is the likely primary
tumour?

1- Pancreas

2- Colorectal

3- Ovarian

4- Liver

5- Prostate

Answer & Comments

Answer: 1- Pancreas

The tumour markers are not specific to one
tumour but in this case the Ca 19.9 is highest,
and it is most strongly associated with
pancreatic cancer.

[ Q: 2256 ] MRCPass - 2011 May
Which is the site of action of thiazide

diuretics?

1- Proximal part of Distal Convoluted Tubule

2- Distal part of Distal Convoluted Tubule

3- Proximal convoluted tubule

4- Loop of Flenle

5- Collecting duct

Answer &. Comments

Answer: 1- Proximal part of Distal Convoluted
Tubule

Thiazide diuretics reduce the reabsorption of
sodium and chloride in the early part of the
distal convoluted tubule of the kidney.

This results in the delivery of increased
amounts of sodium to the distal tubule, where
some of it is exchanged for potassium. The net
result is increased excretion of sodium,
potassium and water.

SPIRONOLACTONE

INHIBITORS Of
M«*.Cr SYMPORTER

THIAZIDES

ALDOSTERONE

INHIBITORS

Hm* CHANNEL
BLOCKERS

TRIAMTERINE
AMI LOR IOC

DIURETICS

INHIBITORS OF

Hm*. K*. acr SYMPORTER

FUROSEMIDE
BUMETANIOE
ETHACRYNC ACID

INHIBITORS OF
CARBONIC ANHYDRASE

ACETAZOLAMIDE

I-►

[ Q: 2257 ] MRCPass - 2011 May

A 62 year old man presents with
lethargy and weight loss which has occurred
over a period of 4 months. He has a history of
hypertension and diabetes. He was admitted
to hospital and investigated for the symptoms.
A CT scan of the abdomen confirmed that he
had sigmoid colon carcinoma which was
localised. His blood results showed that he
had a urea of 15 mmol/l and creatinine 180
umol/l. Urine dip stick showed protein ++++
and blood +. A renal biopsy was performed.
Shortly after this, the patient underw ent a
colectomy as an inpatient. He recovered well
and was discharged. A follow up appointment
was arranged to review the renal biopsy result
it was observed that the proteinuria
improved.

What is the likely histology of the glomerular
lesion ?

1- Minimal change glomerulonephritis

2- Membranoproliferative glomerulonephritis

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3- Membranous nephropathy

4- Focal segmental glomerulosclerosis

5- IgA nephropathy

Answer & Comments

Answer: 3- Membranous nephropathy

The scenario shows nephrotic range
glomerular disease, as this resolved after the
colectomy it suggests an association which is
most likely membranous nephropathy
associated with carcinoma.

Membranous nephropathy is caused by
circulating immune complexes which are
formed by binding of antibodies to antigens in
the glomerular basement membrane.

85 % of membranous nephropathy cases are
idiopathic.

About 15% of cases are secondary due to:

autoimmune conditions (e.g., systemic lupus
erythematosus)

infections (e.g., syphilis, malaria, hepatitis B)

drugs (e.g., captopril, NSAIDs, gold, mercury,
penicillamine, probenecid).

tumors, frequently solid tumors of the lung
and colon; hematological malignancies such as
chronic lymphocytic leukemia are less
common.

Normal glomerular Membranous glomerulopathy
capillaries with thin walls with thick capillary walls

^ [ Q: 2258 ] MRCPass - 2011 May

m A 62 year woman has presented with
new sudden jerky movements of her arm. She
has a history of diabetes mellitus and is on
insulin. She describes sudden onset of wild
flinging movements of left arm which are
worse when she is doing physical work. When
she rests the movements appear to lessen.
This movement can occur up to every few
minutes.

Where is the likely site of the lesion?

1- Substantia nigra

2- Contralateral subthalamic nucleus

3- Non dominant parietal

4- Caudate nucleus

5- Cerebellar

Answer & Comments

Answer: 2- Contralateral subthalamic nucleus

The hemiballismus (swinging arm movements)
is likely be due a lesion in the subthalamic
nucleus.The movements are often violent and
have wide amplitudes of motion.

They can be continuous and random. The
facial muscles, arms and legs can be involved.
The more a patient is active, the more the
movements increase. With relaxation comes a
decrease in movements.

The subthalamic nucleus innervates other
structures within the basal ganglia, including a
very important connection to the inside of the
globus pallidus. The subthalamic nucleus
essentially provides the excitement needed to
drive the globus pallidus. Injury to the
subthalamus or its efferent or afferent
connections can induce hemiballismus.
Although traditionally thought that the
disorder was only caused by injury to the
subthalamic nucleus, new studies show that
damage to other areas of the brain can also be
responsible for causing this disorder.

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Causes can be due to a vascular lesion
(stroke), trauma, neurodegeneration (motor
neuron disease) and demyelination.

Subthalamic Nucleus

[ Q: 2259 ] MRCPass - 2011 May

A 51 year old man with a past history
of alcohol abuse presents with a painful red
and warm ankle which was tophaceous. Gout
was diagnosed and he was prescribed
allopurinol.

Whot is allopurinol's mechanism of action?

1- Uricosuric drug

2- Non steroidal anti inflammatory drug

3- Microtubule inhibitor

4- Xanthine oxidase inhibitor

5- Dihydrofolate reducatase inhibitor

Answer & Comments

Answer: 4- Xanthine oxidase inhibitor

Hypouricaemic agents essentially comprise of
xanthine oxidase inhibitors (for example,
allopurinol) and uricosuric agents (for
example, probenecid, sulphinpyrazone or
azapropazone).

Standard teaching is that urate lowerring
drugs should not be introduced during an
acute episode as it may worsen or prolong the

episode; furthermore initiation of
hypouricaemic treatment may precipitate
acute gout. Colchicine and NSAIDs can be used
in the acute situation.

[ Q: 2260 ] MRCPass - 2011 May

A 53 year old patient e was referred
to the outpatient clinic with a history of
recurrent pruritic lesions of 9 months'
duration, which were initially located on the
elbow s, periumbilical areas, and subsequently
on the back and shoulders. The patient
reported that milky-w hite areas of skin had
appeared 4 years previously, and these areas
had remained unchanged. He had not sought
any treatment for this condition. A
dermatologist suspects dermatitis

herpetiformis.

What should be done to confirm this?

1- Anti gliadin antibody

2- Anti endomysial antibody

3- Small bowel biopsy of the intestine

4- immunofluorescence of perilesional skin for
IgA

5- Trial of steroids

Answer & Comments

Answer: 4- immunofluorescence of

perilesional skin for IgA

In dermatitis herpetiformis, the biopsy sample
should be taken from the edge of a lesion for
hematoxylin and eosin staining and from
normal-appearing perilesional skin for direct
immunofluorescence staining.

Granular IgA deposits in dermal papillae of
perilesional skin observed by direct
immunofluorescence is the criterion standard
of diagnosis.

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Direct immunofluorescence with linear IgA
deposits along the dermal epidermal junction

[ Q: 2261 ] MRCPass - 2011 May

A 42 year old type I diabetic is
referred for renal investigations. She has been
suffering from Rheumatoid arthritis for the
last 20 years. She is currently on insulin
injections, ibuprofen and penicillamine. She
had 4 + proteinuria on a urine dipstick and
quantification with 24 hour urine collection
revealed that she had urinary protein > 4.5
g/day.

Ultrasound of the abdomen shows increased
renal echogenicity.

Investigations :

Hb 11.5 g/dl

MCV 82 fl

WCC 12 x 10 9 /l

platelets 225 x 10 9 /l

sodium 135 mmol/l

potassium 4.5 mmol/l

Urea 14 mmol/l

Creat 215 umol/l

A renal biopsy shows eosinophilic deposits
within the mesangium on light microscopy.
The basement membrane and epithelial space
is normal.

Whot is the probable diagnosis?

1- Minimal change nephropathy

2- Membranous nephropathy

3- Diabetic nephropathy

4- NSAIDS induced nephropathy

5- Amyloidosis

Answer & Comments

Answer: 5- Amyloidosis

Diabetic nephropathy is unlikely to cause such
heavy proteinuria, hence amyloidosis due to
rheumatoid arthritis is the most likely
diagnosis.

Membranous nephropathy can present
similarly, but is more commonly associated
with autoimmune diseases (e.g.

SLE), infections (e.g. hepatitis B) and
malignancy (e.g. lymphoma).The drugs for
rheumatoid arthirits ie NSAIDS, penicillamine
gold can cause membranous nephropathy.
The renal biopsy will show small subepithelial
deposits in the glomeruli which can also lead
to spikes or thickening of the basement
membrane but the mesangium is typically
normal.

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• • •

A •

• Tubules j %

\ V.% ; V *

; ' >V? A*

/ ‘ V k Glomeruli with^* ,\I ^ ^ J */

amyloid deposits •* ‘ nt V^r/U

[ Q: 2262 ] MRCPass - 2011 May

A 60 year old man presented with
back pain. On examination, he had normal
tone bilaterally. There was absent ankle jerk
reflex on the right. He also had decreased
touch and pain sensation on the lateral side of
the right. The plantar reflex was normal on the
left and upgoing on the right. The anal tone
was normal and there was no evidence of
saddle anaesthesia.

What it the likely diagnosis?

1- Peripheral neuropathy

2- Lumbar spinal canal stenosis

3- Cauda equina

4- Posterolateral disc prolapse at L5-S1

If the prolapse is very large and presses on the
spinal cord or the cauda equina syndrome
may occur. Compression of the cauda equina
can cause permanent nerve damage or
paralysis. In cauda equina syndrome, the
nerve damage can result in bilateral leg
weakness and pains, saddle anaesthesia and
loss of bow el and bladder control as well as
sexual dysfunction.

^ [ Q: 2263 ] MRCPass - 2011 May

ft -

A 18 year woman with mild Von
Willebrand's disease was scheduled for dental
extraction. A previous dental extraction
resulted in bleeding and had required two
units of blood for transfusion.

What is the appropriate treatment prior to
dental surgery?

1- Cryoprecipitate

2- DDAVP

3- Fresh frozen plasma

4- High purity factor VIII concentrate

5- Recombinant factor VIII concentrate

Answer & Comments

Answer: 2- DDAVP

5- Subacute combined degeneration of the
cord

Answer & Comments

Answer: 4- Posterolateral disc prolapse at L5-
S1

A prolapsed intervertebral disc typically
causes lower back pain and pain radiating
down the legs (sciatica).

The L5/S1 disc is the disc most commonly
damaged. With a posterolateral herniation,
disc will affect the nerve corresponding to the
lower level in this case SI. The absent ankle
reflex and lateral foot sensory loss is
consistent with an SI root lesion.

DDAVP is the treatment of choice for mild
disease, which would include Type I, majority
of Type II.

It of limited use in Type III - severe Von
Villebrand's disease. The history indicates that
she has mild disease. For severe disease one
would use a Von Willebrand factor
concentrate, factor VIII concentrate.

[ Q: 2264 ] MRCPass - 2011 May

A 63- year-old male was admitted
with a history of severe recurrent attacks of
central abdominal pain radiating to both
hypocondria, occasionally associated with
vomiting. He used to be a heavy smoker and
admitted to a moderate alcohol consumption.

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On examination, he had no signs of chronic
liver disease and there were no palpable
masses.

What is the investigation of choice to confirm
suspected chronic pancreatitis?

1- Endoscopic ultrasound

Alcohol withdrawal delirium (delirium
tremens) is the clinical syndrome of
disorientation, perceptual disturbance and
psychomotor agitation.

Visual hallucinations are commonly
associated.

2- CT scan of the abdomen

3- Barium enema

4- Colonoscopy

5- Flexible sigmoidoscopy

Answer & Comments

Answer: 2- CT scan of the abdomen

A secretin simulation test is considered the
gold standard functional test for diagnosis of
chronic pancreatitis.

Korsakoff's psychosis is associated short term
memory loss, subsequent compensatory
confabulation by patient.

Other symptoms may include delirium,
anxiety, fear, depression, confusion, delusions
and insomnia.

[ Q: 2266 ] MRCPass - 2011 May

What is the mode of inheritance of
the disease Hereditary Haemorrhagic
Telangiectasia?

CT scan of the abdomen is useful because 1- Autosomal recessive

longstanding inflammation often causes 2- Autosomal dominant

calcification of the pancreas. , , , ,

3- X-linked dominant

[ Q: 2265 ] MRCPass - 2011 May

A 58 patient has been admitted with
confusion. The patient's relatives describe that
he does not remember the events that
occurred in the last day but recognised them.
He also seemed to make up events which he
did not remember. On examination, he had an
MMSE score of 22 / 30. He was tremulous in
both his hands and had an ataxic gait. Tone,
power and reflexes were normal in both upper
and lower limbs.

What is the likely diagnosis?

4- X-linked recessive

5- Polygenic inheritance

Answer & Comments

Answer: 2- Autosomal dominant

There are four forms of Hereditary
Hemorrhagic Telangiectasia.

Inheritance is autosomal dominant. HHT 1 is
associated with a mutation in the endoglin
gene, and HHT 2 is associated with a mutation
in the alkl gene.

1- Alzheimer's dementia

2- Lewy body disease

3- Korsakoff's psychosis

4- Creudsfeldt Jakob disease

5- Normal pressure hydrocephalus

HHT is characterised by telangiectasia (small
vascular malformations on the skin and
mucosal linings (as shown in the diagram
below ), epistaxis (nosebleeds), and
arteriovenous malformations (AVMs) in
various internal organs.

Answer & Comments

Answer: 3- Korsakoff's psychosis

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[ Q: 2267 ] MRCPass - 2011 May

A 16 year old boy presents with
discoloured urine. He describes having had a
sore throat 5 days ago but has recovered from
the symptoms. The urine dipstick shows blood
+++, protein +. Renal function was normal on
the blood tests. A renal biopsy is likely to show
which of the following on light microscopy?

1- Crescents

tj Increased cellularity
y in glomeruli

Reduced
Bowman spaces

[ Q: 2268 ] MRCPass - 2011 May

An 18 year old girl with
meningococcal meningitis has further
investigations as this is her 3rd episode of
meningitis. It was found that she had low
properdin levels measured by the ELISA test.
How is this likely to have been inherited?

2- Collapsed glomeruli

3- Normal tissue

1- Autosomal dominant

2- Autosomal recessive

4- Segmental glomerulosclerosis

5- Mesangial hypercellularity

Answer & Comments

Answer: 5- Mesangial hypercellularity

The age , sex and almost simultaneous
presentation of sore throat with haematuria
suggests IgA nephropathy.

It is a common cause of macroscopic
haematuria in a child. It also occurs commonly
in young adults. Episodes of haematuria are
often simultaneous with periods of viral
infection (sore throat) and flank pain. The
urine may be frankly bloody or may be cola
colour. There are clots in urine. It usually
resolves spontaneously within

4-7days.Renal biopsy will show mesangial IgA
deposition on immunofluorescence, light
microscopy will show mesangial
hypercellularity with matrix expansion.

3- X linked recessive

4- X linked dominant

5- Mitochondrial inheritance

Answer & Comments

Answer: 3- X linked recessive

Complement deficiencies are relatively rare
worldw ide, and estimates of prevalence are
based on results from screening high-risk
populations.

Retrospective studies of persons with
frequent meningococcal infections report

varying prevalence based on geographic
location. In populations with recurrent
meningococcal infection, the prevalence rate
is as high as 30%.

The majority of complement deficiencies are
inherited in an autosomal recessive patter. An
exception to the autosomal pattern of
inheritance is properdin deficiency, which is
an X-linked trait.

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The pathw ays include the classic pathway
(Clqrs, C2, C4), the alternative pathway (C3,
factor B, properdin).

Properdin stabilizes the C3 convertase (C3bBb)
of the alternative pathw ay, involved in
opsonisation. Meningococcal disease is a
prominent manifestation in a significant
fraction of reported cases in all clinical
patterns of complement deficiency,
particularly those where opsonisation is
defective. Properdin deficiency states are X-
linked recessive, while other genetic defects
within the complement system appear to be
transmitted as autosomal recessive traits.

[ Q: 2269 ] MRCPass - 2011 May

A 20 year old female is referred to
the hospital. Her family are concerned about
her because she has been very agitated in the
last 2 days. She has no past medical history of
note. The sister said that she was hearing
voices.

On examination, she looks restless and
physical examination is normal.

Whot is the likely couse of this presentation?

1- Alcohol

2- Barbiturates

3- Diazepam

4- Amphetamines

5- Opiates

Answer & Comments

Answer: 4- Amphetamines

This patient is likely to have taken a stimulant
which has made her restless and agitated with
some psychotic features.

The most common stimulants taken as
recreational drugs are amphetamines and
cocaine.

[ Q: 2270 ] MRCPass - 2011 May

A 70 year old lady has longstanding
lethargy. On physical examination she had a
plethoric face & conjunctival injection.
Investigations revealed:

hemoglobin 17.5 g/dl (12-16 g/dl)

red cell count 8.1 M/?l (3.5 to 6 M/?l)

Hct. 58.% (37 to 52%)

MCV 65.7fL (67 to 96 fL)

MCH 19.6 pg (27 to 32 pg)

WBC 13.1 x 10 9 /l

ESR 2 mm/hour

Blood film showed erythrocytosis,
thrombocytosis and leucocytosis.

With the diagnosis in mind, which one of the
following is likely to be associated?

1- JAK2 mutation

2- P53 mutation

3- EGFR mutation

4- NPAT mutation

5- MYD88 mutation

Answer & Comments

Answer: 1- JAK2 mutation

The diagnosis in this case is polycythaemia
rubra vera.

Janus kinase 2 (commonly called JAK2) is a
human protein

that has been implicated in signaling by
members of the type II cytokine receptor
family. These mutations have been associated
with polycythemia vera, essential
thrombocythemia, and other

myeloproliferative disorders.

[ Q: 2271 ] MRCPass - 2011 May

A 55 year old lady presents with
sudden onset bilateral lower limb weakness
half a day ago. On examination there was loss

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of pain and temperature sensation (T12
downw ards) but joint position sense and
vibration sense was preserved bilaterally. Both
the lower limbs were hyperreflexic with
upgoing plantars.

What is the diagnosis?

1- Severe combined degeneration of the cord

2- Anterior spinal artery infarction

3- Multiple sclerosis

4- Brown Sequard Syndrome

5- Motor neuron disease

Answer & Comments

Answer: 2- Anterior spinal artery infarction

The typical clinical features of spinal artery
infarction include:

Answer & Comments

Answer: 2- Southern blotting

A Southern blot is a method routinely used in
molecular biology for detection of a specific
DNA sequence in DNA samples.

Southern blotting combines transfer of
electrophoresis-separated DNA fragments to a
filter membrane and subsequent fragment
detection with a hybridisation probe.

-sudden radicular pain and para- or quadra-
paresis

-limbs initially flaccid but within days, become
spastic

The Western blot is a technique involving
electrophoresis to detect specific proteins in
the given sample of tissue homogenate or
extract (e.g. in HIV testing, or to detect prions
in Bovine Spongiform Encephalopathy).

-reflexes initially absent but within days,
become hyper-reflexic with extensor plantars

-loss of pain and temperature sensation up to
the level of cord damage - due to involvement
of anterolateral

spinothalamic tracts

-urinary and faecal incompetence from lesions
in the lower lumbar / sacral areas

[ Q: 2272 ] MRCPass - 2011 May

Which one of the following
techniques is used to detect DNA using a
labelled probe for hybridisation?

[ Q: 2273 ] MRCPass - 2011 May

A 30 year old Caucasian man
presented with 2 weeks of gradually
worsening vision in his left eye with
alterations in seeing colours. The patient also
describes pressure and tightness with left eye
movement for the past week. The patient
reported his vision in the left eye worsened
when show ering. On examination, there was
no ptosis. His pupils were reactive to light, and
there was a left afferent pupillary defect. Slit
lamp exam was normal. Goldmann visual
fields and showed a central scotoma on the
left.

1- Northern blotting

2- Southern blotting

3- Eastern blotting

4- Western blotting

5- Polymerase chain reaction

What is the likely diagnosis?

1- Acute glaucoma

2- Optic neuritis

3- Retinitis pigmentosa

4- Anterior uveitis

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5- Retinal vein thrombosis

Answer & Comments

Answer: 2- Optic neuritis

Optic neuritis typically presents with a triad of
symptoms: loss of vision, colour changes and
eye pain.

The initial attack is unilateral in 70% of adult
patients and bilateral in 30%. The mean age of
onset of optic neuritis is in the third decade of
life, but can occur FROM the first to the
seventh decades.Associated visual symptoms
are reduced perception of light intensity and
Uhthoff's symptom (visual deficit induced by
exercise or increased body temperature). The
visual loss may be subtle or profound.

The most common etiology is multiple
sclerosis. Up to 50% of patients with MS will
develop an episode of optic neuritis. Some
other causes of optic neuritis include infection
( Syphilis, Lyme disease, herpes zoster),
autoimmune disorders (SLE) and drugs (e.g.
chloramphenicol, Ethambutol).

surface of the plasma membrane and
transmembrane receptors of hormones.

[ Q: 2274 ] MRCPass - 2011 May

G-proteins coupled receptors are
located in which part of the cell?

1- Cell membrane

2- Mitochondrion

3- Nucleus

4- Cytoplasm

5- Nuclear membrane

Answer & Comments

Answer: 1- Cell membrane

G proteins are so-called because they bind the
guanine nucleotides GDP and GTP.

They are heterotrimers (i.e., made of three
different subunits) associated with the inner

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[Q: 2275] MRCPass - 2011
September

A 55-year-old woman presents with periods of
sweats and tremors which are relieved by
eating. She has gained approximately 6 kg in
weight in the last 2 years. Her BM is 4.5. Blood
tests are: Hb 13 g/dl, MCV 78 fl, WCC 7 x 10 9 /l,
platelets 200 x 10 9 /l, sodium 135 mmol/l,
potassium 4.7 mmol/l, urea 5 mmol/l,
creatinine 100 |imol/l, TSH - 3.3 (0.3-4) mU/l,
free T4 -20 (10-24) pmol/l.

Whot is the most appropriate investigation?

1- 72 hour fast

2- CT scan of pancreas

3- MRI of the brain

4- Insulin C-peptide concentration

5- Oral glucose tolerance test

Answer & Comments

Answer: 1- 72 hour fast

This patient has symptoms suggestive of
hypoglycaemia which are relieved by
carbohydrate.

The likely cause is an insulinoma which is an
insulin secreting pancreatic tumour.

pupil was larger than the left. The pupillary
reflex on the right eye was also sluggish both
to light and accomodation. Eye movements
and fundoscopy were normal.

What is the diagnosis?

1- Argyll Robertson pupil

2- Horner's syndrome

3- Holmes Adie pupil

4- Myasthenia gravis

5- 3rd nerve palsy

Answer & Comments

Answer: 3- Holmes Adie pupil

Holmes-Adie syndrome (HAS) is a neurological
disorder affecting the pupil of the eye and the
autonomic nervous system.

It is characterised by one eye with a pupil that
is larger than normal and constricts slow ly in
bright light (tonic pupil), along with the
absence of deep tendon reflexes, usually in
the Achilles tendon. HAS is thought to be the
result of a viral or bacterial infection that
causes inflammation and damage to neurons
in the ciliary ganglion. It is more common in
women than men.

Measurement of C-peptide is useful in
excluding factitious hypoglycaemia from self
injection of insulin. Insulin preparations do not
contain C-peptide.

1 g i

A 31 year old female patient was referred by
the GP for assessment of unequal sized pupils.
On examination, it was found that the right

[Q: 2276] MRCPass-2011
September

[Q: 2277] MRCPass-2011
September

A 41-year-old female patient presents with a
1-year history of recurrent episodes of vertigo.
The vertigo spells are described as a sensation
of the room spinning that lasts from 20
minutes to a few hours and may be associated
with nausea and vomiting. The spells are
incapacitating and are accompanied by
dizziness, vertigo, and disequilibrium, which
may last for days.

The patient also reports tinnitus, and hearing
loss in the right ear that is more pronounced
around the time of her vertigo spells. Physical
examination of the head and neck is normal.
There was no nystagmus. She is unable to

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maintain her position during Romberg's
testing. She turns tow ards the right side and
she is unable to walk tandem. Her cerebellar
function tests are normal.

What is the diagnosis?

1- Cerebellar disorder

2- Vestibular neuronitis

3- Meniere's disease

4- Labyrinthine disease

5- Internuclear opthalmoplegia

Answer & Comments

Answer: 3- Meniere's disease

Meniere's disease is a disorder of the inner
ear that can affect hearing and balance to a
varying degree.

It is characterized by episodes of vertigo and
tinnitus and progressive hearing loss, usually
in one ear. Nystagmus can occur, but is not
typical. Vestibular neuronitis and larynthine
disease do not typically cause deafness.

A 26 year-old woman with a history of
depression is brought to the hospital with
decreased conscious level and a brief seizure.
She had taken an overdose of tricyclic
antidepressants 12 hours prior. Her GCS is
12/15, she is tachycardic to 120 bpm and her
blood pressure is 96/62 mmHg. She appears
flushed and her skin is dry. A blood gas shows:

pH -7.15

p02 -13.3 kPa

pC02 -3.5 kPa

base excess - negative 8.5

What should be given?

1- Gastric Lavage

2- Charcoal

3- 8.4% bicarbonate infusion

[Q: 2278] MRCPass-2011
September

4- Naloxone infusion

5- Flumazenil infusion

Answer & Comments

Answer: 3- 8.4% bicarbonate infusion

In a patient who is acidotic who is at risk of
cardiac arrhythmias and seizures, serum
bicarbonate is recommended.

[Q: 2279] MRCPass-2011
September

A 56 year old man with schizophrenia has
been prescribed olanzepine.

Which one of the following is a side effect?

1- Hirsutism

2- Impotence

3- Diarrhoea

4- Weight gain

5- Malignancy

Answer & Comments

Answer: 4- Weight gain

Olanzepine is an antipsychotic which is said to
block serotonin receptors.

Antagonism of dopamine receptors is
associated with extrapyramidal effects such as
tardive dyskinesia. Antagonizing HI histamine
receptors causes sedation and may cause
weight gain (90% of users). Dry mouth,
sedation and urinary retention are other side
effects.

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[Q: 2280] MRCPass - 2011
September

A 25 year old lady returned from Hong Kong
(she had been there for 2 months). 2 weeks
after she returned to the UK and she
complained of fever, chills, severe myalgias
and arthalgia. Past medical, surgical, family
history and review of systems were
unremarkable. On examination, temperature
was 39.6 C. There was a generalized petechial
rash in the lower part of the body. Her blood
tests revealed the following results:

Hb 11.0 g/dl,
WCC 12 x 10 9 /l,

platelets 250 x 10 9 /l

aspartate transaminase (AST) of 319 (1-31)
U/L

alanine transaminase (ALT) of 198 (5-35) U/L
alkaline phosphatase of 74 (20-120) U/L
What is the most likely diagnosis?

1- Dengue fever

2- Tyhoid fever

3- Lassa virus

4- Acute HIV infection

5- p falciparum malaria

Answer & Comments

Answer: 1- Dengue fever

Fever, thrombocytopenia and petechial rash
are typical of dengue fever.

fever. Rash, gastrointestinal pain, and diarrhea
are common manifestations of the syndrome.

The fever typically lasts for 5-7 days. It is often
self limiting. Upon resolution of the fever,
patients may run the risk of hemorrhagic
symptoms (epistaxis, ecchymoses, and
gastrointestinal bleeding) and plasma leakage
syndrome (hemoconcentration, ascites, or
pleural effusions) called dengue hemorrhagic
fever. Dengue hemorrhagic fever may have a
mortality of 5% in those untreated. Treatment
is supportive ( e.g. iv fluids)

What is the most likely diagnosis?

1- Alcoholic encephalopathy

2- Subarachnoid haemorrhage

3- Complex partial seizure

4- Transient ischaemic attack

5- Transient global amnesia

Answer & Comments

Answer: 5- Transient global amnesia

[Q: 2281] MRCPass-2011
September

Dengue fever is caused by a
mosquitotransmitted flavivirus that is endemic
throughout much of the tropical world.
Symptoms arise 4-7 days after the bite of a
mosquito, but can be as short as 3 days or a
long as 14 days following insect exposure. The
clinical syndrome of classic dengue fever is
characterized initially by headache, retro-
orbital eye pain, and severe myalgias and
arthalgias originally termed "breakbone"

Transient global amnesia (TGA) is a syndrome
in clinical neurology whose key defining
characteristic is temporary but almost total
disruption of short-term memory with a range
of problems accessing older memories.

A person in a state of TGA exhibits no other
signs of impaired cognitive functioning but
recalls only the last few moments of
consciousness plus deeply-encoded facts of
the individual's past, such as his or her own

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name. It may last several hours. The most
commonly cited precipitating events include
vigorous exercise (including sexual
intercourse), sw imming in cold water or
enduring other temperature changes, and
emotionally traumatic or stressful events.

[Q: 2282] MRCPass - 2011
September

A 67 year old lady has epigastric pain for
several months and is referred for endoscopy.
Biopsy confirms MALT lymphoma.

Whot is the treatment of choice?

1- Chemotherapy

2- Radiotherapy

3- Interferon

4- Surgery

5- H.pylori eradication

forced expiratory volume in one second
(FEV1) of 2.09 I (predicted 3.18 I)

forced vital capacity (FVC) of 2.33 I (predicted
4.04).

Carbon monoxide transfer factor (TLCO) was
reduced to 67% predicted.

There was 5% improvement following
salbutamol nebulisers.

Whot is the likely diagnosis?

1- COPD

2- Asthma

3- Pulmonary embolus

4- Interstitial lung disease

5- Pneumothorax

Answer & Comments

Answer: 4- Interstitial lung disease

Answer & Comments

Answer: 5- H.pylori eradication

Most cases of MALT lymphoma affecting the
stomach are associated with infection by a
bacterium called Helicobacter pylori (often
abbreviated to H.

pylori). If tests confirm its presence then a
course of intensive antibiotic treatment will
sometimes lead to a remission of the
lymphoma.

[Q: 2283] MRCPass-2011
September

A 50-year-old woman was admitted because
of progressive shortness of breath. She has
been a smoker of 5 cigarettes a day for the
past two years. She has a past medical history
of seropositive rheumatoid arthritis,

diabetes mellitus and hypertension. On
examination the fingers were clubbed and
there were bilateral basal crepitations.

Lung function tests showed :

Although there is slight improvement with
salbutamol, the best answer is interstitial lung
disease/ pulmonary fibrosis.

The FEV1 / FVC ratio is 90% which suggests
restrictive lung disease rather than obstructive
lung disease.

There is also reduced transfer factor. This is
likely to be due to the history of rheumatoid
arthritis in this case.

[Q: 2284] MRCPass-2011
September

A 36 year old Caucasian female presented with
malaise, joint pains , Raynaud's phenomenon
and shortness of breath for the last 6 months.
On physical examination she was afebrile and
had a supine blood pressure of 110/80mm Hg.
Her apex beat was displaced, she had a loud
P2 and a right ventricular heave. There were
fine basal crepitations in both lung bases on
auscultation. Blood tests revealed:

Hb 11.5 g/dl, MCV 85 fl

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erythrocyte sedimentation rate of 80 mm/first
hour

sodium 135 mmol/l
potassium 4.5 mmol/l
urea 18 mmol/l
creatinine 285 |imol/l

antinuclear antibody (ANA) - strongly positive

antitopoisomerase I antibody (formerly anti
SCL-70 antibody) positive

normal C3 and C4

anti-DNA, anti-centromere, anti-RNP, anti-Ro
and La antibodies - negative

Whot is the likely diagnosis?

1- Hereditary haemorrhagic telangiectasia

2- Sjogren's syndrome

3- Wegener's granulomatosis

4- Oesophageal carcinoma

[Q: 2285] MRCPass - 2011
September

A blood test has been used to screen for the
likelihood of gastric cancer. The results are as
follows:

Cancer Diagnosed

No Cancer

Positive

Negative

What is the positive predictive value?

1- 25%

2- 33.3%

3- 50%

4- 60%

5- 66.6%

Answer & Comments

Answer: 3- 50%

5- Diffuse systemic sclerosis

Answer & Comments

Answer: 5- Diffuse systemic sclerosis

The patient is likely to have a diffuse form of
scleroderma.

The positive predictive value of a test is the
probability that the patient has the disease
when restricted to those patients who test
positive.

This term is sometimes abbreviated as PPV.
You can compute the positive predictive value
as

The limited cutaneous form of scleroderma is
CREST syndrome (calcinosis, raynauds,
esophageal dysmotility, sclerodactyly and
telangiectasia).

In diffuse scleroderma, antinuclear antibodies
are present in about 95% of patients.

Topoisomerase I antibodies (formerly Scl-70)
are present in approximately 30% of patients
with diffuse disease (absent in limited disease)
and are associated with pulmonary fibrosis.

PPV = TP/(TP + FP)

where TP and FP are the number of true
positive and false positive results,
respectively. In this case, the TP is 60, FP is 60
and PPV is 60/120 = 50%.

A 42-year-old female presented with an
erythematous annular patch with central
clearing on her left foot. She has returned
from a walking holiday 1 week ago. The
patient mentioned that the rash has gotten
progressively larger and spreading up the leg
over the last 3 weeks and she has had a recent
onset of intermittent joint pains.

[Q: 2286] MRCPass - 2011
September

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On examination, there is a large area of
erythema with a central clearing over the calf
and the foot.

What test is likely to confirm the diagnosis?

1- Borrelia burgdoferi

2- Wuchereria bancrofti

3- Spirochaetes

4- Echinococcus granulosus

5- Trypanosomiasis cruzi

Answer & Comments

Answer: 1- Borrelia burgdoferi

Lyme Disease (LD) is a multisystem disease
affecting the nervous system, skin, joints, and
heart.

It is endemic in the

temperate regions of the northern
hemisphere (United States, Europe, Canada).
Erythema migrans (EM), the characteristic
dermatologic lesion of LD, is an expanding red
papule or macule with central clearing, often
found in the axilla, midriff, or popliteal areas.

B. burgdorferi is transmitted by the tick
Ixodes, a hard bodied tick found in wooded
areas. Lyme disease occurs in 3 stages: early
localized, early disseminated, and late. If left
untreated, each stage progresses to the next.
Early localized disease manifests within 3-30
days presenting with erythema migrans (EM),
myalgia, fatigue, headache, fever,
lymphadenopathy, and arthralgia. Early
disseminated disease occurs 30 to 120 days
post-infection and is characterized by EM
(single or multiple), fatigue,
lymphadenopathy, conjunctivitis, neck pain,
cardiac abnormalities, radiculoneuritis,
arthritis, and CNS manifestations. Late disease
manifests from 4 months to 1 year, presenting
with fatigue, chronic arthritis, CNS
manifestations, and encephalopathy.

First-line treatment for early disease is
doxycycline (100 mg PO twice a day for 14 to

21 days) or amoxicillin (500 mg PO three times
a day for 14 to 21 days).

A 18 year old man has presented for
investigation with haematuria. On his urine
dipstick, there were blood ++.

What is the likely diagnosis?

1- Polyarteritis nodosa

2- Systemic lupus erythematosus

3- Alport's syndrome

4- Ig A nephropathy

5- Exercise induced haematuria

[Q: 2287] MRCPass-2011
September

Answer & Comments

Answer: 3- Alport's syndrome

Alport's syndrome leads to a
glomerulonephritis.

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[Q: 2288] MRCPass - 2011
September

A 28 year old girl develops sudden onset left
sided weakness and dysarthria which resolves
fairly promptly. She has just returned from
Australia 2 days previously. Physical
examination is normal.

What test is likely to identify the underlying
couse?

1- Transthoracic echocardiogram

2- Transoesophageal echocardiogram

3- Carotid dopplers

4- MRI of the brain

5- EEG

Answer & Comments

Answer: 2- Transoesophageal echocardiogram

This patient had a transient ischaemic attack.

As she is young, she is most likely to have a
patent foramen ovale which will be diagnosed
with a transoesophageal echocardiogram
(usually with a bubble contrast study)

The purine analogues azathioprine and
mercaptopurine are effective in inducing and
maintaining remission in patients with
ulcerative colitis and Crohn's disease.

Azathioprine is a prodrug which is converted
to mercaptopurine and the enzyme thiopurine
methyltransferase (TPMT) breaks down
mercaptopurine. Deficiency of the enzyme is
associated with a greater risk of
myelosuppression.

[Q: 2290] MRCPass - 2011
September

A 43-year-old man has recently been
diagnosed with non-Hodgkin's lymphoma. He
has a long history of alcoholism and has
significant alcohol-related peripheral
neuropathy.

Which one of the following chemotherapy
agents should be avoided?

1- Chlorambucil

2- Cyclophosphamide

3- Epirubicin

4- Vincristine

[Q: 2289] MRCPass-2011
September

A 36 year old lady has Crohn's disease with
poorly controlled symptoms. She also has a
history of chronic anaemia.

Which enzyme should be checked before
starting the drug azathioprine?

1- Thiopurine methyltransferase

2- Glycogen phosphorylase

3- Creatinine kinase

4- Myeloperoxidase

5- Acetylcholinesterase

Answer & Comments

Answer: 1- Thiopurine methyltransferase

5- Rituximab

Answer & Comments

Answer: 4- Vincristine

Vincristine (brand name, Oncovin), also known
as leurocristine, is a vinca alkaloid.

The main side-effects of vincristine are
peripheral neuropathy (which can be severe),
hyponatremia and hair loss.

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^ [ Q: 2291 ] MRCPass - 2011

S September

A 60 year old lady presented with a fall but did
not sustain a fracture. She experienced
menopause in her early 50s and initiated
hormone therapy (HT) with
es-trogen/progestin for her menopausal
symptoms. She has polymyalgia rheumatica
and has been on prednisolone for the last 1
year. She was organised to have a DEXA scan.
This showed a T score of -2.6 in the hip.

Whot should be prescribed?

1- Vitamin D

He also seemed to make up events which he
did not remember. On examination, he had an
MMSE score of 22 / 30. He was tremulous in
both his hands and had an ataxic gait. Tone,
power and reflexes were normal in both upper
and lower limbs.

What is the likely diagnosis?

1- Alzheimer's dementia

2- Lewy body disease

3- Korsakoff's psychosis

4- Creudsfeldt Jakob disease

5- Normal pressure hydrocephalus

2- Calcichew

3- Teriparatide

4- Bisphosphonates

5- Raloxifene

Answer & Comments

Answer: 4- Bisphosphonates

This patient is postmenopausal and is likely to
have steroid related osteoporosis.

Bisphosphonates are thought to inhibit the
activation and function of osteoclasts, and are
the drug of choice in this scenario. Examples
are Alendronate and risedronate, which are
licensed for the treatment of osteoporosis in
post-menopausal women, and the prevention
of osteoporosis in those post-menopausal
women considered to be at risk. The NICE
guidelines recommend that bisphosphonates
are used as treatment for preventing bone
fractures in postmenopausal women who
have had osteoporosis diagnosed but have not
had a fracture.

A 59 patient has been admitted with
confusion. The patient's relatives describe that
he does not remember the events that
occurred in the last day but recognised them.

[Q: 2292] MRCPass - 2011
September

Answer & Comments

Answer: 3- Korsakoff's psychosis

Alcohol withdrawal delirium (delirium
tremens) is the clinical syndrome of
disorientation, perceptual disturbance and
psychomotor agitation.

Visual hallucinations are commonly
associated.

Korsakoff's psychosis is associated short term
memory loss, subsequent compensatory
confabulation by patient.

Other symptoms may include delirium,
anxiety, fear, depression, confusion, delusions
and insomnia.

[Q: 2293] MRCPass-2011
September

A 61 year old lady has pain in her knees,
shoulders, wrists and fingers. Examination of
her hands reveals multiple symmetrical small
joint involvement. The proximal and distal
joints were affected. Joint X rays show the
presence of osteophytes and
chondrocalcinosis. She is currently on
bendrofluazide and metformin tablets. A urate
level on admission was 420 (<380 |imol/l). The
rheumatoid factor was positive with a titre of
1:30.

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What is the diagnosis?

1- Polyarticular gout

2- Pseudogout

3- Systemic lupus erythematosus

4- Haemochromatosis

4- Post streptococcal glomerulonephritis

5- Goodpasture's syndrome

Answer & Comments

Answer: 3- IgA nephropathy

5- Rheumatoid arthritis

Answer & Comments

Answer: 2- Pseudogout

The diagnosis would fit with a subcategory of
calcium pyrophosphate deposition disease.

Pseudogout is one manifestation of calcium
pyrophosphate deposition disease, where
joint aspiration fluid might show
rhomboidshaped, positively birefringent
crystals. It affects the knees most commonly
and can involve the proximal interphalangeal
(PIP) joints and spine. Osteophytes and
chondrocalcinosis are a common radiological
finding . In addition, older individuals may
have low -titer-positive rheumatoid factor as
in this case.

[Q: 2294] MRCPass - 2011
September

A 21 year old man was referred for pink
discolouration of his urine to the hospital. He
had no previous relevant medical history. 3
days ago he complained of a sore throat and
was given a course of amoxicillin and
ibuprofen by the GP but those symptoms have
resolved now . On examination, he looked
well. His blood pressure was 120/70 mmHg,
temperature 36 C. There were normal
abdominal examination and he had no
palpable organomegaly. Urine dipstick showed
blood ++, Protein +, nitrites negative.

What is the most likely diagnosis?

1- Crescentic glomerulonephritis

2- Wegener's granulomatosis

3- IgA nephropathy

IgA nephropathy is the most common
glomerulonephritis and is characterized by
deposition of the IgA antibody in the
glomerulus.

[Q: 2295] MRCPass-2011
September

A 43 year old man is known to have HIV. He
develops multiple fleshy, red nodules on the
trunk which were diagnosed as Kaposi's
sarcoma.

What is the aetiological agent?

1- Cytomegalovirus

2- Ebstein barr virus

3- Coronavirus

4- HHV 8

5- Parvovirus

Answer & Comments

Answer: 4- HHV 8

HHV-8, is a gammaherpesvirus found only in
humans.

Kaposi's sarcoma (KS) is caused by Human
herpesvirus 8 (HHV8) and frequently found in

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patients with HIV infection. Kaposi's sarcoma
lesions may appear like bruises but are
papular. With time, they darken. Scarring is
common following treatment with
immunosuppressive drugs.

A 18 year old man has a a history of 2 months
of bumps in the left axilla. Initially there was
just 1 lesion but now the man has 6 lesions.
Some of the areas have been inflamed, and
the man has pruritus, which keeps him up at
night. One of his cousins, with whom he swam
with regularly, may have such lesions as well.
He develops multiple fleshy, red nodules on
the trunk. These were treated but healed with
mild scarring.

Which one of the following is most likely?

1- Molluscum contagiosum

2- Kaposi's sarcoma

3- Human papillovirus infection

4- Herpes zoster infection

5- Herpes simplex infection

[Q: 2296] MRCPass - 2011
September

Answer & Comments

Answer: 1- Molluscum contagiosum

Molluscum contagiosum is a viral skin disease
characterised by firm, round, translucent,
umbilicated papules containing caseous
matter and peculiar capsulated bodies.

It is caused by a DNA virus of pox family. This
common viral disease has a higher incidence
in children, sexually active adults, and those
who are immunodeficient. It can appear with
crops and can be treated with cryotherapy. It
tends to be self limiting.

[Q: 2297] MRCPass-2011
September

What is the mechanism of action of the drug
aspirin ?

1- Monoclonal antibody

2- Cyclooxygenase inhibitor

3- Glycoprotein llb/llla inhibitor

4- ADP antagonist

5- Low molecular weight heparin

Answer & Comments

Answer: 2- Cyclooxygenase inhibitor

Aspirin also known as acetylsalicylic acid is a
salicylate drug.

Aspirin is classified under nonsteroidal anti¬
inflammatory drugs (NSAIDs), but differs from
them in the mechanism of action. Like other
NSAIDS, it inhibits the same enzyme
cyclooxygenase (COX), However it affects
more the COX-1 variant than the COX-2
variant of the enzyme

[Q: 2298] MRCPass-2011
September

A 40-year-old man presented with an initial
complaint of dyspnea on exertion that had
developed five years prior and had progressed
to shortness of breath while walking up one
flight of stairs. He has a history of
osteoarthritis. He experienced significant
inorganic dust exposure while working as a
builder. He does not smoke and drinks 2 units
of alcohol per day.

Physical examination revealed pulmonary
auscultation that was remarkable for a
prolonged expiratory phase without wheezes
or rhonchi. The remainder of his physical
examination was unremarkable. A chest x ray
showed hyperinflated lungs with large bullae

Pulmonary function testing at presentation
demonstrated :

forced expiratory volume in one second
(FEV1) was 2.10 litres (61% of the predicted
value)

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forced vital capacity (FVC) was 3.60 litres (81%
of the predicted value) the FEV1:FVC ratio was
0.58

total lung capacity (TLC) was 6.40 litres (93%
of the predicted value)

residual lung volume (RV) was 2.91 litres
(123% of the predicted value)

Stool weight chart (fasting - 850 mis / day)
Faecal stool osmolality 295 mosmol/kg
What is the likely diagnosis?

1- Laxative abuse

2- VIPoma

3- Giardiasis

There was minimal response to an inhaled
bronchodilator.

What is the likely diagnosis?

1- Smoking related COPD

2- Bronchiectasis

4- Irritable bowel syndrome

5- Crohn's disease

Answer & Comments

Answer: 2- VIPoma

3- Alpha 1 antitrypsin deficiency

4- Silicosis

5- Usual interstitial pneumonitis

Answer & Comments

Answer: 3- Alpha 1 antitrypsin deficiency

Alpha 1-antitrypsin deficiency is an autosomal
recessive genetic disorder caused by defective
production of alpha 1-antitrypsin (A1AT),
leading to decreased A1AT activity in the
lungs, and deposition of excessive abnormal
A1AT protein in liver cells.

Severe A1AT deficiency causes panacinar
emphysema or COPD in adult life. The case
above demonstrated severe emphysema, and
in a non smoker with young age onset the
patient is likely to have an inherited cause
such as A1AT deficiency.

A 28 year old lady complained of watery
diarrhoea for the past few weeks. On
investigation of blood tests and stool
collections, the following results were
obtained:

Na 138 mmol/l

K 2.5 mmol/l

[Q: 2299] MRCPass - 2011
September

VIPoma (Verner Morrison syndrome) is a rare
(1 per 10,000,000 per year) endocrine tumor,
usually (about 90%) originating in the
pancreas, that produces vasoactive intestinal
peptide (VIP).

The massive amounts of VIP in turn cause
profound and chronic watery diarrhea and
resultant dehydration, hypokalemia,
achlorhydria, acidosis, vasodilation (flushing
and hypotension), hypercalcemia and
hyperglycemia.

Clinical diagnosis is based on a history of
approximately 10 watery stools per day.
Fasting stool volume > 750 to 1000 mL/day) is
diagnostic. Fecal losses while fasting are at
least 20 mL/kg/d but exceed 50 mL/kg/d in
most cases.

Fecal osmolality is entirely accounted for by
twice the sum of the concentrations of sodium
and potassium, indicating the electrolyte loss.
Patients may complain about colicky
abdominal pain or pain in the upper
abdominal area radiating to the back.

[Q: 2300] MRCPass-2011
September

A 46 year old woman experienced visual
disturbance. The patient reported blurred
vision and oscillopsia on downgaze, but did
not complain of double vision.

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Ophthalmological examination showed
decreased near visual acuity. Examination of
eye motility showed bilateral weakness of the
inferior and lateral rectus muscles.

Downbeat nystagmus on down and lateral
gaze was seen clinically.

What is the likely diagnosis?

1- Grave's eye disease

2- Cerebellar tumour

3- Arnold Chiari malformation

4- Sagittal meningioma

5- Horner's syndrome

Answer & Comments

Answer: 3- Arnold Chiari malformation

In the Arnold-Chiari malformation a part of
the brainstem and the cerebellum are
herniated into the cervical vertebral canal.

The cerebellar tonsils are elongated and
pushed down through the opening of the
foramen magnum, blocking the flow of
cerebrospinal fluid. Clinical findings include
oscillopsia, impaired smooth pursuit, and
OKN, and in many cases downbeat nystagmus.
Patients may experience no symptoms or
remain asymptomatic until early adulthood, at
which point they will often experience severe
headaches and neck pain. Fatigue, dizziness,
vertigo, neuropathic pain, visual disturbances,
difficulty sw allowing, ringing in the ears may
also occur.

[Q: 2301] MRCPass - 2011
September

A 35 year old woman with anxiety is
hyperventilating acutely after hearing stressful
news.

What would be expected on the arterial blood
gas?

1- Low P02

2- High PC02

3- Normal pH

4- Low bicarbonate

5- Low H+ ion

Answer & Comments

Answer: 5- Low H+ ion

In a patient who is hyperventilating, C02 is
blown off.

Since carbon dioxide is carried as bicarbonate
in the blood, the loss of carbon dioxide will
drive bicarbonate to combine with hydrogen
ions (protons) to form more carbon dioxide.
The loss of hydrogen ions results in the blood
becoming alkaline, i.e. the blood pH value
rises. This is known as a respiratory alkalosis. If
the hyperventilation continues, then a drop in
bicarbonate levels may occur due to renal
clearance after several hours, but the question
refers to the acute situation where H+ is low ,
but not bicarbonate.

A 25 year old known asthmatic was admitted
with an acute exacerbation of her problem.
She was given lOOmg of IV Hydrocortisone
and 2 doses of salbutamol and ipratropium
nebulization. Her PEFR was measured on
admission as 200 (Predicted 550). After 2
doses of salbutamol and Ipratropium
nebulization the peak flow did not improve
beyond 210 and she was still dyspnoeic.

What should be the next step in the
management?

1- Salbutamol

2- Aminophylline

3- Na cromoglycate

4- IV Magnesium

5- Antibiotics

[Q: 2302] MRCPass-2011
September

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Answer & Comments

Answer: 4- IV Magnesium

A single dose of IV magnesium sulphate has
been shown to be safe and effective in acute
severe asthma who did not had a good initial
response to inhaled bronchodilator therapy in
life threatening or near fatal asthma.

[Q: 2303] MRCPass-2011
September

A 62 year old man with a history of excessive
alcohol use presented with a fall and lost
consciousness for several minutes.

He was brought to hospital and was initially
alert. However, whilst he was awaiting
assessment he complained of a headache and
his GCS deteriorated from 15 to 8. He also
became acutely confused.

What is the most likely diagnosis?

1- Subarachnoid haemorrhage

2- Subdural haemorrhage

3- Diffuse axonal injury

4- Epileptic seizure

5- Somatization

Answer & Comments

Answer: 2- Subdural haemorrhage

The patient who fell over may have injured his
head and the most likely cause of a further
sudden deterioration in conscious level with
an associated headache is a subdural
haemorrhage or haematoma.

This patient needs an urgent CT scan in view
of the deterioration.

[Q: 2304] MRCPass-2011
September

A 72 year old woman has been referred for
management of a blood pressure of 190/100
mmHg. She has a history of bipolar disorder

and peripheral vascular disease. She is
currently on aspirin and lithium.

Which one of the following is the best
antihypertensive agent to commence?

1- Valsartan

2- Lisinopril

3- Amlodipine

4- Atenolol

5- Doxazosin

Answer & Comments

Answer: 3- Amlodipine

According to the British Hypertension Society
guidelines, Patients who are > 55 in age or
black should be on either a calcium channel
blocker (C) or thiazide diuretic (D).

Amlodipine is a calcium channel blocker hence
the best option here. Both thiazides and ACE
inhibitors can increase lithium concentration
levels.

[Q: 2305] MRCPass-2011
September

A 19 year old lady presents with amenorrhoea
and is investigated in clinic. She is sexually
active and had normal periods up till 1 year
ago. Her pregnancy tests across 6 months
were negative. The patient has a body mass
index of 28. She has normal stature and
cardiac, respiratory examination are normal.

Laboratory evaluation reveals the following:

prolactin level of 215 (50-450) ng/mL

LH 22 (0.5-14.5) IU/L

FSH 44 (1-11) IU/L

(3-HCG - negative

Which one of the following is most likely?

1- Premature ovarian failure

2- Panhypopituitarism

3- Adrenal tumour

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4- Polycystic ovary disease

5- Turner's syndrome

Answer & Comments

Answer: 1- Premature ovarian failure

Premature ovarian failure is defined as
menopause occurring in women prior to the
age of 40 years.

Diagnosis requires elevated gonadotrophins -
FSH above 40 IU per litre together with raised
LH and low oestradiol (less than 100 pmol per
litre) on at least two occasions. Ultrasound
usually reveals small ovaries, a small uterus
and a thin endometrium in premature ovarian
failure.

Cure rates for appropriately managed
(including both medical and surgical therapies)
native valve endocarditis are as follows:

• For S viridans and S bovis infection, the rate
is 98%.

• For enterococci and S aureus infection in
individuals who abuse intravenous drugs, the
rate is 90%.

• For community-acquired S aureus infection
in individuals who do not abuse intravenous
drugs, the rate is 60-70%.

• For infection with aerobic gram-negative
organisms, the rate is 40-60%.

• For infection with fungal organisms, the rate
is lower than 50%.

[Q: 2306] MRCPass - 2011
September

A 62-year-old man with exertional dyspnea,
fever and malaise. He had altered bow el habit
for several weeks prior to his admission. On
examination his temperature was 39.5 C ,
there was sinus tachycardia of 105 beats/min
and respiratory rate was 32/minute. There
was a systolic murmur along the apex and
diastolic murmur at the right second
intercostal area. He was arranged to have
urgent trans-thoracic echocardiography which
revealed vegetations on both the mitral
valves. Blood cultures were taken.

Which of the following organisms, if cultured
confers the best prognosis?

1- Streptococcus mitis

2- Enterococcus

3- Streptococcus viridans

4- Staphylococcus aureus

5- Streptococcus milieri

[Q: 2307] MRCPass - 2011
September

A 58-year-old non alcoholic patient was
admitted to hospital for investigation of
hematemesis and melena.

On admission, he looked pale and had a Hb of
8 g/ dl. Urgent endoscopy was organised and
this showed grade 2 oesophageal varices.

What treatment should be undertaken?

1- Intravenous octreotide

2- Intravenous terlipressin

3- Intravenous fluids

4- Banding of varices

5- Oral propanolol

Answer & Comments

Answer: 4- Banding of varices

This patient has bleeding oesophageal varices
and thus banding should be undertaken.

Answer & Comments

Answer: 3- Streptococcus viridans

Oesophageal varices are graded according to
their size, as follows:

Grade 1 - Small, straight esophageal
varices

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Grade 2 - Enlarged, tortuous

esophageal varices occupying less

than one third of the lumen
■ Grade 3 - Large, coil-shaped

esophageal varices occupying more
than one third of the lumen

[Q: 2308] MRCPass - 2011
September

A 41-year-old man is investigated for
deterioration in his liver function tests.

It is decided to perform a liver biopsy.

Which one of the following is o
contraindication to liver biopsy?

1- INRof 1.4

2- ALT of 250 u/l

3- Platelet count of 110 x 10 9 /l

4- Obesity with BMI of 35 kg/m * 1 2 3 4

5- Biliary duct dilatation on the ultrasound

More information can be found in this
document:

http://gut.bmj.eom/content/45/suppl_4/IVl.f

ull

[Q: 2309] MRCPass-2011
September

A 16 year old girl presented with a
polyarthritis and haematuria. She has noticed
a discolouration of her urine and a rash in the
legs. On examination, she has a non blanching
purpuric rash in both her shins. Blood results
show that the urea is 16 mmol/I and
creatinine 210 umol/l.

What is the most likely outcome of the renal
involvement?

1- High probability of relapse

2- Complete renal recovery

3- Persistent hypertension

4- Development of nephrotic syndrome

5- Long-term corticosteroids required

Answer & Comments

Answer: 5- Biliary duct dilatation on the
ultrasound

The best answer here is biliary duct dilatation,
which increases the risk of infection as there
might be cholestasis or cholecystitis.

Many would consider obesity, but it is not an
absolute contraindication.

A short list of contraindications to liver biopsy
are:

Prolonged (>1.6) international normalized
ratio (INR)

The platelet count should exceed 60xl0 A 9/l

There should be no biliary dilatation or major
ascites

Bleeding diathesis (eg, hemophilia)

Answer & Comments

Answer: 2- Complete renal recovery

This patient is likely to have Henoch-Schonlein
purpura (HSP), which is a self-limited systemic
vasculitis.

It is suspected to be triggered by an IgA-
mediated response to an antigen. It is
characterized by 4 clinical syndromes:

1. Palpable purpura in the absence of
thrombocytopenia or coagulopathy. Develops
in 100% of patients.

2. Arthritis/arthralgia in 45-75% of patients.
Second most common manifestation of HSP.

3. Abdominal pain in 50%, Gl bleeding (often
occult) in 20-30% of patients.

4. Renal disease in 20-50%.

Full renal recovery is the commonest outcome
(90%) in HSP.

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[Q: 2310] MRCPass - 2011
September

A 36 year old female who has been on thyroid
replacement therapy has routine thyroid
function tests. On examination, she appeared
clinically euthyroid with no abnormal findings.
Her blood tests showed:

TSH 3.8 mU/L (0. 35 - 5.0)

Total T4 18 nmol/L (55 -144)

free T4 5.2 pmol/L (9 - 24)

Total T3 2.4 nmol/L (0. 9 - 2.5)

Which one of the following is the likely
scenario?

1- She is taking thyroid supplements
unnecessarily

2- She has secondary hypothyroidism

3- She has sick euthyroid syndrome

4- Her thyroid hormone replacement is
adequate

5- She should have a short synacthen test

Answer & Comments

Answer: 4- Her thyroid hormone replacement
is adequate

In hypothyroidism TSH provides a good
measure of treatment adequacy and the
picture is consistent with adequate
replacement despite the low T4 levels.

A 30 year old man presents with persistent
diarrhoea and fevers.

The diarrhoea did not improve despite fluids
and ciprofloxacin treatment. He has known
HIV infection and his most recent CD4 count
was 45.

Which one of the following is the likely
pathogen?

1- Salmonella

[Q: 2311] MRCPass-2011
September

2- Mycobacterium avium intracellulare

3- Shigella

4- Campylobacter

5- Rotavirus

Answer & Comments

Answer: 2- Mycobacterium avium

intracellulare

MAC rarely causes disease in individuals with a
normal immune system.

In patients with AIDS (CD4 count < 50),
However, it is one of the most common
serious opportunistic infections. Patients most
commonly report persistent fever, night
sweats, fatigue, weight loss, and anorexia.
Abdominal pain or chronic diarrhea may result
from involvement of retroperitoneal lymph
nodes or gut mucosa, respectively.

[Q: 2312] MRCPass-2011
September

A 42-year-old man has recently started
treatment for pulmonary tuberculosis. He has
a history of diabetes and osteoarthritis. Prior
to starting treatment, which one of the
following tests should be done?

1- Full blood count

2- Urea and electrolytes

3- ESR

4- Coagulation screen

5- Liver function test

Answer & Comments

Answer: 5- Liver function test

The standard treatment for tuberculosis is a 6-
month, four-drug initial regimen (6 months of
isoniazid and rifampicin supplemented in the
first 2 months with pyrazinamide and
ethambutol).

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Anti-tuberculosis chemotherapy is associated
with abnormalities in liver function tests in 10-
25% of patients. Several anti-tuberculosis
agents have been implicated as being
hepatotoxic. Isoniazid (particularly in
association with rifampicin) and pyrazinamide
cause hepatic dysfunction more frequently
than ethambutol and streptomycin.

A 38-year-old man went for a holiday in Belize.
He presented with a non-healing ulcer on the
nasal area after 6 weeks. The lesion started as
an itchy red papule which slow ly enlarged
into an ulcerated plaque. He remembered
being bitten by sandflies during his stay in
Belize. There were no systemic symptoms. The
ulcer failed to heal despite several courses of
systemic antibiotics. There was no relevant
past medical or drug history of note.

On examination, he had a was noted to have a
2 cm x 1.8 cm crusted, ulcerated plaque on
the upper, inner aspect of the left nasal area.
There were no regional or generalized
lymphadenopathy and no muco-cutaneous
changes.

What is the likely diagnosis?

1- Behcet's disease

2- Cutaneous leishmaniasis

3- Syphilis

4- basal cell carcinoma

[Q: 2313] MRCPass - 2011
September

sandfly and remain subclinical. However, in
some cases, after an incubation period of 1-12
weeks, a papule develops that enlarges and
ulcerates. The typical lesion are crusty,
painless ulcers on exposed skin.

Ulcerative lesions are usually shallow and
circular with well-defined, raised borders and
a bed of granulation tissue. Local
lymphadenopathy only occurs in the presence
of bacterial superinfection. Cutaneous
leishmaniasis is found predominantly in South
America, Central Africa, around the
Mediterranean Sea and India

[Q: 2314] MRCPass-2011
September

A 61 year old lady is being assessed for
treatment of hypertension. She has a high
blood pressure despite being on
bendroflumethiazide. She has recently
discontinued medications due to ankle
oedema, gum bleeding and generalised
lethargy.

What medication should she be given?

1- Atenolol

2- Perindopril

3- Amlodipine

4- Verapamil

5- Frusemide

Answer & Comments

5- Squamous cell carcinoma

Answer: 2- Perindopril

Answer & Comments

Answer: 2- Cutaneous leishmaniasis

Cutaneous leishmaniasis is spread by female
sandflys of the genus Phlebotomus.

The causative agents include L. (V.)
braziliensis, L. (L.) mexicana, L. (V.)
panamensis, and related species. Most
infections follow a bite from an infected

Beta blockers may worsen lethargy and
calcium channel blockers can cause ankle
oedema and gum bleeding.

A thiazide diuretic has already been started,
hence frusemide is not appropriate, hence an
ACE inhibitor such as perindopril is the best
option.

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[Q: 2315] MRCPass - 2011
September

Which organ listed below is with direct contact
with left kidney?

1- Liver

2- Duodenum

output from the a-cells of the pancreas, which
results in decreased hepatic glucose output.

Gliptins are recommended as an option in
type 2 diabetes for patients with inadequate
glycaemic control despite being on metformin,
sulphonylureas and glitazones.

3- Small intestine

4- Pancreas

5- Colon

Answer & Comments

Answer: 4- Pancreas

The left kidney is anatomically next to the
spleen and pancreas.

A type 2 diabetic with poor glycaemic control
on metformin and rosiglitazone was then
started on sitagliptin.

What is the mechanism of action of gliptins?

1- Binds to PPAR gamma

2- Sulphonylurea secretagogue

3- Alpha glucosidase inhibitor

4- Glucagon like peptide

5- Dipeptidyl peptidase 4 inhibitor

[Q: 2316] MRCPass-2011
September

Answer & Comments

Answer: 5- Dipeptidyl peptidase 4 inhibitor

Dipeptidyl peptidase-4 inhibitors (DPP-4s),
also commonly called gliptins, are a relatively
new class of drugs for the treatment of type 2
diabetes.

Examples are vitagliptin and sitagliptin. These
agents work in a unique way to improve
insulin secretion from the Beta-cells of the
pancreas in response to an increase in blood
sugar and simultaneously decrease glucagon

[Q: 2317] MRCPass-2011
September

A 41 year old man is admitted with fevers and
a cough productive of green sputum. His
friends had similar presenting symptoms. On
investigation the blood results showed
macrocytosis and chest x ray shows a right
upper lobe cavitating lesion.

What is the most likely cause?

1- Haemophilus influenzae

2- Klebsiella

3- Legionella

4- Streptococcus pneumoniae

5- Mycoplasma

Answer & Comments

Answer: 2- Klebsiella

Klebsiella infection most common in men over
40 years of age and is most frequently found
in alcoholics.

Other predisposing factors are heart or lung
disease, diabetes and malignancy. There is
often sudden with severe systemic upset (high
fever, rigors) and pleuritic pain. The sputum is
purulent, gelatinous or blood-stained
(haemoptysis occurs more often than in most
bacterial pneumonias) Consolidation is usually
seen in the upper lobes and may be extensive
- sw elling of the infected lobe may result in
bulging of the fissures on the lateral chest X-
ray.

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A 17 year old female is evaluated in the
pediatric endocrinology clinic for primary
amenorrhoea.

Which one of these features is consistent with
testicular feminisation or androgen
insensitivity syndrome?

1- Male phenotype with lack of hair

2- Male phenotype with inguinal testis

3- Male phenotype with breast development

4- Female phenotype with clitoromegaly and
undescended testis

5- Female phenotype with external male
genitals

Answer & Comments

Answer: 4- Female phenotype with

clitoromegaly and undescended testis

Androgen insensitivity syndrome (AIS),
formerly known as testicular feminization, is
an X-linked recessive condition.

eek history of a progressive malaise. He had
been commenced 5 days of antibiotic
treatment by his GP no improvement was
noted. On examination he had several
palpable cervical and axillary lymph nodes. He
did relate a history of exposure to cats at
home and had scratch mark on his chest.

What is the likely organism?

1- Bartonella hensalae

2- Pasteurella multicoda

3- Pseudomonas

4- Staph aureus

5- Candida

Answer & Comments

Answer: 1- Bartonella hensalae

The genus Bartonella (formerly Rochalimaea)
is a member of the rickettsial order of
bacteria, and it is found worldwide.

The most likely mode of bacterial transmission
is an infected cat, hence the term 'Cat Scratch'
disease.

[Q: 2318] MRCPass - 2011
September

An 18 year old man was referred with a 6-w

[Q: 2319] MRCPass-2011
September

Cat-to-cat transmission is believed to be
attributable to fleas.

[Q: 2320] MRCPass-2011
September

A 36-year-old man is admitted with left-sided
pleuritic chest pains. These pains have been
occurring for the past 2 weeks. Prior to the
onset of the pains, he had been experiencing
flu-like symptoms.

What is the ECG most likely to show ?

1- SI, Q3, T3

2- Atrial fibrillation

3- Widespread ST elevation

4- ST segment depression in the anterior leads

5- Tented T waves

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Answer & Comments

Answer: 3- Widespread ST elevation

The diagnosis is likely to be pericarditis
(possibly viral aetiology) and classical ECG
changes of saddle shaped ST elevation are
expected

[Q: 2321] MRCPass - 2011
September

What is the mode of inheritance of vitamin D
resistant rickets?

1- Autosomal recessive

2- Autosomal dominant

3- X linked Recessive

4- X linked dominant

5- Sporadic

Answer & Comments

Answer: 4- X linked dominant

X-linked hypophosphatemic or Vitamin D
resistant Rickets is an X-linked dominant
disorder characterized by growth retardation,
rachitic and osteomalacic bone disease,
hypophosphatemia, and renal defects in
phosphate reabsorption and vitamin D
metabolism

A 34-year-old Caucasian woman admitted has
a history of widespread, pruritic,
erythematous skin rash, joint pains and renal
disease.

She recently had a baby with congenital heart
block. Laboratory investigations revealed mild
leucopenia (white cell count 3.25 x 10 9 /ml)
and thrombocytopenia (platelets 140 x
10 9 /ml). Erythrocyte sedimention rate was
increased (65 mm/h).

Which antibody is likely to be positive?

1- Anti Jo 1

[Q: 2322] MRCPass - 2011
September

2- Anti double stranded DNA

3- Anti Ro

4- Anti centromere

5- ANCA

Answer & Comments

Answer: 3- Anti Ro

The anti Ro antibody is associated with
Sjogren's syndrome, SLE and neonatal lupus.

Neonatal lupus erythematosus (NLE) is a rare
disorder caused by the transplacental passage
of maternal autoantibodies. Only 1% of infants
with positive maternal autoantibodies develop
neonatal lupus erythematosus. The most
common clinical manifestations are cardiac
(congenital heart block), dermatologic
(urticaria and skin desquamation) , and
hepatic (abnormal LFTs). The mother produces
immunoglobulin G (IgG) autoantibodies
against Ro (SSA), La (SSB), and/or Ul-
ribonucleoprotein (Ul-RNP), and they are
passively transported across the placenta.
These autoantibodies can be found alone or in
combination; However, anti-Ro is present in
almost 95% of patients.

^ [ Q: 2323 ] MRCPass - 2011

• September

A 55 year old man presented with severe
retrosternal chest pain. His ECG shows ST
depression in leads VI to V4. He has been
given Fondaparinux.

What is the drug's mechanism of action?

1- Tissue plasminogen activator

2- GIIBIIIA inhibitor

3- Factor X a inhibitor

4- Low molecular weight heparin

5- Antithrombin III inhibitor

Answer & Comments

Answer: 3- Factor X a inhibitor

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Fondaparinux is a synthetic pentasaccharide
Factor Xa inhibitor.

It is used for the prevention of deep vein
thrombosis , pulmonary embolism and for
management of acute coronary syndrome.
One potential advantage of fondaparinux over
LMWH or unfractionated heparin is that the
risk for heparin-induced thrombocytopenia
(HIT) is substantially lower.

[Q: 2324] MRCPass - 2011
September

An 18 year man whose brother had
hypertrophic cardiomyopathy was referred for
a cardiological assessment.

His echocardiogram confirmed the above
condition.

Which one of following echocardiographic
features is an important risk factor for sudden
cardiac death?

1- Gradient of 30 mmHg across left ventricular
outflow tract

2- Septal wall thickness of > 3 cm

3- An enlarged left atrium

4- Systolic anterior motion of mitral valve

5- The presence of mitral regurgitation

Answer & Comments

Answer: 2- Septal wall thickness of > 3 cm

Patients die of hypertrophic obstructive
cardiomyopathy by obstructing left ventricular
outflow tract (LVOT), usually during exercise.

The greater thickness of septum, more likely
there is risk of cardiac arrhythmias (> 3 cm is
significant).

[Q: 2325] MRCPass - 2011
September

Which one of following cells in lung
parenchyma produces surfactant?

1- Alveolar macrophage

2- Endothelial cell

3- Goblet Cell

4- Type I pneumocyte

5- Type II pneumocyte

Answer & Comments

Answer: 5- Type II pneumocyte

Surfactant is produced by type II
pneumocytes.

Type II pneumocytes also called great alveolar
cells or septal cells are granular and roughly
cuboidal in shape. Type II pneumocytes are
typically found at the alveolar-septal junction.

[Q: 2326] MRCPass-2011
September

A 25 year old man has had behavioural
disturbance recently. His parents mentioned
that his brother has been investigated for liver
problems recently. On examination, he has a
MMSE score of 28/30. He has a mask like face
and was noticed to have hypersalivation.
When the investigations are complete, which
drug is most likely to be used for treatment?

1- Desferrioxamine

2- Co careldopa

3- Penicillamine

4- Interferon alpha

5- Chlorpromazine

Answer & Comments

Answer: 3- Penicillamine

The likely diagnosis is Wilson's disease.

Most patients who present with
neuropsychiatric manifestations have
cirrhosis. The most common presenting
neurologic feature is asymmetric tremor,
occurring in approximately half of individuals
with Wilson disease. Frequent early symptoms
include difficulty speaking, excessive

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salivation, ataxia, masklike facies, clumsiness
with the hands, and personality changes. The
disease is autosomal recessive.

Penicillamine is used as a copper chelator.

A 22 year old man is tall compared to his
peers. On examination, he was found to have
aortic incompetence and mitral valve
prolapse. He also had pectus excavatum,
arachnodactyly and arm span greater than
height. Slit lamp examination revealed had
upward dislocation of the lens in the eye.

The gene defect is:

1- Actin

2- Myosin

3- Fibrillin

4- Retinoblastoma

5- Elastin

[Q: 2327] MRCPass-2011
September

Answer & Comments

Answer: 3- Fibrillin

The fibrillin gene defect is the basis of
Marfan's syndrome.

It is an autosomal dominant disorder
characterised by arachnodactyly, upward lens
dislocation, tall habitus and flat feet. Aortic
aneurysms and aortic regurgitation are also
associated.

[Q: 2328] MRCPass-2011
September

A 20-year-old female college student presents
with increased polydipsia and polyuria since
childhood. She has alw ays feels thirsty and
has a frequency of micturition of 20 to 25
times in a 24-hour period. She mentions that
she has had the symptoms for 2 months. Upon
investigation the following results were found.

sodium 122 mmol/I

potassium 4.5 mmol/I
urea 4 mmol/l
creatinine 78 |imol/l
Glucose: 5.5 mmol/l

Plasma Osmolality 270 (280-300)

mosm/kgwater

Urine Osmolality 90 (50-1200) mosm/kg

A water deprivation test was conducted and
the urine osmolality increased to 300
mosm/kg and the serum osmolality increased
to 290 mosm/kg after 6 hours.

Whot is the diagnosis?

1- Addison's disease Diabetes mellitus

2- Diabetes mellitus

3- Psychogenic polydipsia

4- Diabetes insipidus

5- SIADH

Answer & Comments

Answer: 3- Psychogenic polydipsia

Primary polydipsia or psychogenic polydipsia
is usually associated with a patient's
increasing fluid intake due to the sensation of
having a dry mouth.

The test of choice to distinguish primary
polydipsia from diabetes insipidus is by fluid
restriction (water deprivation test).

In primary polydipsia, the urine osmolality
should increase and stabilize at above 280
Osm/kg. Stabilization in this test means, more
specifically, when the hourly increase in
osmolality is less than 30 Osm/kg per hour for
at least 3 hours. A stabilization at an
osmolality of less than 280 Osm/kg indicates
diabetes insipidus.

[Q: 2329] MRCPass-2011
September

A 60 year old woman has recently been
diagnosed with small cell carcinoma of the

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lung. She has a 45 pack year smoking history.
She comes to the urgent care clinic today
complaining of a cough and was found to be
confused. The blood tests show :

sodium 119 mmol/l,

potassium 4.2 mmol/l

urea 6 mmol/l

creatinine 80 |imol/l

Plasma Osmolality 260 (280-300) mmol/kgw
ater

Urine Osmolality 380 mmol/kg
Whot is the diagnosis?

1- Addison's disease

2- Diabetes mellitus

3- Psychogenic polydipsia

4- Diabetes insipidus

5- SIADH

Answer & Comments

Answer: 5- SIADH

The syndrome of inappropriate antidiuretic
hormone hypersecretion (SIADH) is
characterized by excessive release of
antidiuretic hormone (ADH or vasopressin)
from the posterior pituitary gland or another
source.

The result is hyponatremia . It is associated
with small-cell carcinoma of the lung,
pneumonia, brain tumors, head trauma,
stroke, meningitis, and encephalitis. In
general, increased ADH causes water
retention and extracellular fluid volume
expansion without edema or hypertension,
owing to natriuresis (the excretion of sodium
by the kidneys). The water retention and
sodium loss both cause hyponatremia, which
is a key feature in SIADH. Hyponatremia and
concentrated urine (UOsm >300 mOsm) are
seen, as well as no signs of edema or
dehydration. Severe hyponatraemia can lead
to cerebral oedema and hence .

^ [ Q: 2330 ] MRCPass - 2011

| I September

Which one of the following is a bod prognostic
marker in acute lymphoblastic leukaemia?

1- Pre-B phenotype

2- Age of < 20 years

3- Initial white cell count of 18 x 10 9 /l

4- Female sex

5- BCR-Abl gene

Answer & Comments

Answer: 5- BCR-Abl gene

Acute lymphoblastic leukaemia (ALL) is most
common in childhood with a peak incidence at
4-5 years of age, and another peak in old age.

Some prognostic factors are:

Sex: females tend to fare better than males.

Age at diagnosis: children between 1-10 years
of age are most likely to develop ALL and to be
cured of it.

Cytogenetics: Philadelphia translocation,

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inhibitors (such as imatinib and sunitinib) are
important drugs against a variety of cancers
including in CML, and sometimes in Ph-
positive acute lymphoblastic leukemia
(Ph+ALL)

A 73-year-old male presents to the emergency
department with sudden-onset, diffuse
abdominal pain that began 18 hours ago. He
has not been vomiting, but he has had several
episodes of diarrhoea, the last of which was
bloody. Ischaemic colitis was diagnosed
following a surgical review.

Where is the most commmon site for the
condition?

1- Hepatic flexure

2- Splenic flexure

3- Caecum

4- Sigmoid

5- Rectum

[Q: 2331] MRCPass - 2011
September

Answer & Comments

Answer: 2- Splenic flexure

The colon receives blood from both the
superior and inferior mesenteric arteries.

[Q: 2332] MRCPass - 2011
September

A 27-year-old man presented with bi¬
temporal hemianopia. He mentioned that his

shoe sizes were above that of his friends since
childhood and he often had sw eaty episodes.

Which one of the following tests is likely to
confirm the diagnosis of acromegaly?

1- Random growth hormone

2- IGF-1

3- Glucose tolerance test with growth
hormone suppression

4- Synacthen test

5- MRI pituitary

Answer & Comments

Answer: 3- Glucose tolerance test with growth
hormone suppression

In Acromegaly, there is excess Growth
hormone (GH) which is difficult to suppress.

[Q: 2333] MRCPass-2011
September

A 53-year-old woman presented to the
emergency department with complaints of
intermittent fatigue, nausea and vomiting for
several months. She complains of having a
constant dry mouth. She had a past medical
history of hypothyroidism and pernicious
anaemia. She had a 20 pack-year smoking
history and alcohol intake consisted of a

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maximum of 4 units a day. On examination,
she was jaundiced and had palpable
hepatomegaly. She was noted to have
excoriation marks on the skin.

Blood results are: Hb 12.5 g/dl, WCC 7 x 10 9 /l,
platelets 235 x 10 9 /l, sodium 136 mmol/I,
potassium 4.5 mmol/I, urea 6 mmol/l,
creatinine 110 pmol/l, ALT 88 (5-35) U/l, AST
55 (1-31) U/l, ALP 520 (20-120) U/l, GGT 85 (4-
35) U/l, Bilirubin 125 (1-22) [irnol/l, Albumin
38 (37-49) g/l.

Whot is the likely diagnosis?

1- Hepatitis B infection

4- Inhibition of sodium channels

5- Inhibition of potassium channels

Answer & Comments

Answer: 5- Inhibition of potassium channels

Most candidates answ ered either inhibition of
sodium or potassium channels.

Although it can be caused by inhibition of
sodium, potassium or calcium channels,
around 90% of inherited long QT syndrome
are due to defects in potassium channels

2- Ulcerative colitis

3- Crohn's disease

4- Primary biliary cirrhosis

5- Gilbert's syndrome

Answer & Comments

Answer: 4- Primary biliary cirrhosis

The patient has a cholestatic picture (high
alkaline phosphatase and bilirubin) in the liver
function tests, and hence out of all the
options, primary biliary cirrhosis is most likely.

There is an association with autoimmune
diseases such as scleroderma, autoimmune
thyroiditis. Fatigue is the first reported
symptom, pruritus is also a common
symptom.

Examination findings usually include
hepatomegaly and xanthelasmata.

«J

A 65 year old man had recently retired and
over the last month has developed symptoms
of trouble concentrating, early morning
waking and poor interest in daily acivities. He
lost his retirement pension in the recession.
He reported current suicidal ideation without
a specific plan but these thoughts were not
recurrent. He hated his life and cried
constantly. He reported that he felt hopeless
and unaw are of future opportunities or
choices in life. He felt "stuck" and "lost." His
wife said that he was often withdrawn.

What is the diagnosis?

1- Mania

2- Depression

3- Schizophrenia

4- Conversion disorder

[Q: 2335] MRCPass-2011
September

[Q: 2334] MRCPass-2011
September

Which one of the following is the most
common underlying physiological mechanism
causing prolongation of the QT segment?

1- Opening of calcium channels

2- Opening of potassium channels

3- Opening of sodium channels

5- Anxiety disorder

Answer & Comments

Answer: 2- Depression

Depression is a state of low mood where
patients may feel sad, anxious, hopeless and
worthless.

They may lose interest in activities that once
were pleasurable, experience loss of appetite,

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or problems concentrating; and may
contemplate or attempt suicide. Insomnia,
excessive sleeping, fatigue, loss of energy are
additional symptoms which may be present.

A 36 year old man presented with a
generalised seizure. On examination, he was
found to have adenoma sebaceum on the
face, two hypopigmented areas and
subungual fibroma. He had a urine dipstick
showing blood ++ and was organised to have
an ultrasound of the kidneys which showed
cystic changes.

What is the likely diagnosis?

1- Von Hippel Lindau

2- Neurofibromatosis

3- Vitiligo

4- Acromegaly

5- Tuberous sclerosis

[Q: 2336] MRCPass - 2011
September

Answer & Comments

Answer: 5- Tuberous sclerosis

The diagnosis is tuberous sclerosis.

It is an autosomal dominant condition.
Features are epilepsy (cortical tubers in the
brain), adenoma sebaceum on the skin,
subungual fibroma of the nails, oval
hypopigmented macules - ash leaf macules -
best seen with Wood's (UV) light, retina
phakoma, renal angiomyolipoma (causing
cystic renal lesions) and cardiac
rhabdomyomas.

[Q: 2337] MRCPass - 2011
September

A 25 year old woman complained of voices
which told her to cut rhis arms, and that she
had heard these voices over the last few days.
She was unemployed and lived with two

friends. Her friends mentioned that she often
takes drugs.

Which one of the following is the most likely
cause of her symptoms?

1- Alcohol

2- Amphetamines

3- Diazepam

4- Gamma-hydroxybutyrate

5- Morphine

Answer & Comments

Answer: 2- Amphetamines

The patient is likely to be having delusions and
amphetamines are the most likely cause.

It tends to occur after large doses and chronic
use.

A 75 year old man with sever COPD was
admitted to hospital with acute shortness of
breath. He was initially alert and the admitting
doctor asked him about escalation of
treatment if he should become unwell. He
understood the question and could repeat the
information back to the doctor. He agreed to
have antibiotics, nebulisers and non invasive
ventilation but refused to have intubation and
ventilation.

An hour later, whilst on non invasive
ventilation, he developed type II respiratory
failure, worsened and became acutely
confused. His GCS dropped to 6 / 15. His
family members became anxious and asked
what was being done for him.

What should be done?

1- Continue antibiotics and nebulisers only

2- Intubate the patient in his best interest

3- Obtain consent from next of kin to intubate
patient

[Q: 2338] MRCPass-2011
September

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4- Increase settings of non invasive ventilation

5- Stop all treatment completely

Answer & Comments

Answer: 1- Continue antibiotics and nebulisers
only

The patient has worsened on non invasive
ventilation (NIV) and is too unwell to tolerate
NIV due to the low GCS.

All are common causes of traveller's
diarrhoea.

However, North Africa and the Middle East (in
particular Egypt) were also commonly
reported regions of travel for Shigella spp
infections.

Some of the infectious causes of bloody
diarrhoea are:

Salmonella

The patient had expressed clear wishes not for
intubation when he had capacity, so it is
inappropriate to obtain consent from next of
kin to go against his wishes.

The best option is to manage conservatively,
hence the patient can have medications but to
explain to the family that he is extremely
unwell and may not survive. Stopping all
treatment abruptly may distress the family at
this point.

[Q: 2339] MRCPass-2011
September

A 31-year-old man who has returned from a
holiday in Egypt presents with diarrhoea. He
had been on a cruise at the Nile river. For the
past two days he has been passing frequent
bloody diarrhoea associated with crampy
abdominal pain. Abdominal examination
demonstrates diffuse lower abdominal
tenderness but there is no guarding or rigidity.
His temperature is 37.8°C.

What is the most likely causative organism?

1- Giardiasis

2- Enterotoxigenic Escherichia coli

3- Staphylococcus aureus

4- Shigella

5- Salmonella

Shigella

Campylobacter jejuni
Yersinia enterocolitica
E. coli

Entamoeba histolytica

[Q: 2340] MRCPass-2011
September

A 77-year-old male presented with a 4-year
history of mild cognitive decline. He has a 10-
year history of hypertension and type 2
diabetes. According to his family, he had
become more forgetful, yet he was able to
carry out simple tasks independently.. His
short-term memory was impaired, as was his
ability to concentrate. His gait was slow and
he was unsteady. He leaned backward when
he walked and fell often, especially when
trying to turn to the left or right. He
experienced urinary frequency, nocturia, and
urinary incontinence at least once a day.

What is the most likely diagnosis?

1- Alzheimer's disease

2- Transient ischaemic attack

3- Lewy body dementia

4- Pick's disease

5- Normal pressure hydrocephalus

Answer & Comments

Answer: 4- Shigella

Answer & Comments

Answer: 5- Normal pressure hydrocephalus

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Normal pressure hydrocephalus (NPH) is a
clinical symptom complex characterized by
abnormal gait, urinary incontinence, and
dementia.

The CT scan often shows evidence of
hydrocephalus (distended ventricles), but the
CSF pressure is normal on lumbar puncture.
The treatment is to remove CSF by lumbar
puncture (normally 50 mis).

[Q: 2341] MRCPass - 2011
September

A 38 year old man was investigated for
infertility. He has a history of hypertension,
diabetes and Crohn's disease. He takes several
medications.

Which one of the following drugs is most likely
to couse this?

unable to get out of bed. Cardiovascular,
respiratory and abdominal examination were
unremarkable. Urine dipstick shows protein
++, blood +++, white cells +.

Whot test should be done?

1- Magnesium

2- Creatine kinase

3- International normalised ratio

4- Troponin

5- Brain natriuretic peptide

Answer & Comments

Answer: 2- Creatine kinase

This patient is likely to have been on the floor
due to weakness and may have
rhabdomyolysis.

1- Mesalazine

2- Sulfasalazine

3- Aspirin

4- Azathioprine

5- Cyclosporin

Answer & Comments

Answer: 2- Sulfasalazine

Sulfasalazine, anabolic steroids,

cyclophosphamide, chlorambucil, busulfan
and cisplatin are drugs which cause
azoospermia.

[Q: 2342] MRCPass-2011
September

A 22-year-old woman presents with a fall and
was found at home with a low conscious level.

She has no significant medical history. A friend
who came with her mentioned that she was
an intravenous drug user and drank 8 - 10
pints of lager a day. On admission, she had a
blood pressure of 95/60 mmHg and
temperature of 34 C. She was very weak and

Monitoring of renal function and urine output
would be important.

[Q: 2343] MRCPass-2011
September

A 43 year old man complained of abdominal
pain, weight loss and diarrhoea for the past
few months. On examination, he had a soft
abdomen with inguinal lymphadenopathy. A
colonoscopy was performed and the small
intestinal biopsy showed PAS stained
macrophages.

Whot is the probable diagnosis?

1- Intestinal lymphoma

2- Whipple's disease

3- Hepatitis

4- Celiac disease

5- Tropical Sprue

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Answer & Comments

Answer: 2- Whipple's disease

Whipple's disease is caused by the organism
Tropheryma whipplei.

It primarily causes malabsorption but may
affect any part of the body including the heart,
lungs, brain, joints, skin, and the eyes. The
clinical features of Whipple's disease include:
malabsorption, weight loss, abdominal pain,
lymphadenopathy, migratory polyarthritis,
sacroiliitis, increased skin pigmentation,
pyrexia, neurological abnormalities.

The disease is regarded as extremely rare,
with an incidence of one case per million
people. The patients are predominantly male
and in their age 40s. T. whipplei appears to be
an environmental organism that is commonly
present in the gasterointestinal tract but
remains asymptomatic . Patients who have
Whipple's disease are thought to have an
immunological defect.

Neut 5.2 xl0 9 /l
Lymp 11.2 x 10 9 /l

Blood Film Atypical lymphocytes seen
Whot is the most likely diagnosis?

1- Acute lymphoblastic leukaemia

2- Hashimoto's thyroiditis

3- Infectious mononucleosis

4- HIV seroconversion

5- Septicaemia secondary to streptococcal
throat infection

Answer & Comments

Answer: 3- Infectious mononucleosis

The small intestinal biopsy in Whipple's
disease reveals:

minimal villous atrophy

PAS positive staining foamy macrophages with
intracellular bacilli (Tropheryma whippelii)

[Q: 2344] MRCPass - 2011
September

A 20-year-old man presents with lethargy,
pyrexia and headaches. These symptoms have
been present for the past 8 days. He had not
been unwell before and there is no recent
history of travel. Clinical examination reveals a
temperature of 37.9°C, marked cervical
lymphadenopathy and mild hepatomegaly.
Throat examination reveals two small
erythematous areas. A full blood count result
shows:

Hb 13.1 g/dl
Platelets 225 x 10 9 /l
WCC 17.1x1071

Atypical lymphocytes are commonly
associated with EBV, CMV and toxoplasma
infection.

Reactive lymphocytes are lymphocytes that
become large as a result of antigen
stimulation.

A 51-year-old male presented with sudden
worsening of breathlessness after a severe
episode of pneumonia was thought to have

[Q: 2345] MRCPass-2011
September

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developed acute respiratory distress
syndrome (ARDS).

Which of the following features would support
a diagnosis of ARDS?

1- High pulmonary capillary wedge pressure

2- High protein pulmonary oedema

3- Hypercapnea

4- Increased lung compliance

5- Normal chest x- ray

Answer & Comments

Answer: 2- High protein pulmonary oedema

Answer: B): high protein pulmonary oedema

ARDS is characterised by hypoxaemia, reduced
lung compliance (stiff lungs) and pulmonary
infiltrates on the chest x- ray.

There is also no cardiogenic cause for
pulmonary oedema (the Pulmonary Capillary
Wedge pressure has to be normal or less than
18mmHg to confirm this).

WCC 12 x 10 9 /l
Platelets 65 x 10 9 /l
sodium 138 mmol/l
potassium 4.7 mmol/l
Urea 22.1 mmol/l
Creatinine 366 pmol/l

Blood film : fragmented red cells and helmet
shaped red cells

What is the likely causative organism?

1- Staphylococcus aureus

2- Neisseria Meningitidis

3- Legionella

4- Leptospira

5- E coli 0157

Answer & Comments

Answer: 5- E coli 0157

The patient has haemolytic uraemic
syndrome.

[Q: 2346] MRCPass-2011
September

A 65-year-old female is brought to A&E by her
family, who are concerned about her
increasing lethargy and confusion over the
past 3 days. There is a history of diarrhea in
the preceding few days. On examination she is
found to be pyrexial at 38oC. Breath sounds
are clear and there is mild tenderness in the
lower abdomen.

Blood tests results show :
Hb 8.6 g/dl

[Q: 2347] MRCPass-2011
September

A 61-year-old man is admitted with chest pain
to the Emergency Department. He has a past
medical history of type 2 diabetes,
hypertension and high cholesterol. His regular
medications includes simvastatin, bisoprolol,
glibenclamide and metformin. An ECG shows
ST elevation in the anterior leads and he is
referred for primary angioplasty. Following
the procedure, he was transferred to the

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Coronary Care Unit (CCU). He has a blood

glucose measurement of 15 mmol/l.

Which drug regime should be commenced?

1- Continue metformin and glibenclamide at
same dose

2- Stop metformin and increase dose of
glibenclamide

3- Subcutaneous insulin: basal-bolus regime

4- Subcutaneous insulin: biphasic insulin
regime

5- Intravenous sliding scale insulin

Answer & Comments

Answer: 5- Intravenous sliding scale insulin

It has been shown from previous trials (e.g.
DIGAMI study) that insulin based glucose
management leads to improved outcomes in
type 2 diabetes post myocardial infarction.
Good glycaemic control can be achieved with
a sliding scale insulin regime or Glucose Insulin
Potassium (GIK) regime.

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jJi

TTiHTT

frrfftrrrtjy rti~t

U waves

[Q: 2349] MRCPass - 2011
September

A 73 year old woman complained of pain at
the base of her right thumb.

On examination, there was tenderness and
swelling of the right first carpo-metacarpal
joint.

What is the most likely diagnosis?

1- Avascular necrosis of the scaphoid

2- De Quervain's tenosynovitis

3- Osteoarthritis

4- Psoriatic arthritis

^ [ Q: 2348 ] MRCPass - 2011

M I L J

S September

On a ECG, which one of the following features
is seen with significant Hypokalaemia?

1- Flattened p wave

2- Prominent r wave

3- Flatttened t wave

4- Prominent u wave

5- Prominent j wave

Answer & Comments

Answer: 4- Prominent u wave

5- Rheumatoid arthritis

Answer & Comments

Answer: 3- Osteoarthritis

The tenderness at the carpometacarpal joint is
most likely due to osteoarthritis in a patient of
this age.

Approximately 40% of post-menopausal
females have radiographic changes at the base
of the thumb. Abnormal loads across the joint
cause the articular cartilage to wear out. Bony
sw elling is apparent in advanced cases and
local palpation at the base of the thumb is
tender.

The prominent U wave is a component seen
after a T wave seen in severe Hypokalaemia.

[Q: 2350] MRCPass-2011
September

A 14 year-old male presents with fever and
headache, and within hours he felt neck pain
when moving his head.

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The following day, his blood pressure fell to
100/70 mmHg, and as a result, he was rushed
to the hospital where he exhibited signs of
confusion. Lumbar puncture was performed,
and the cerebrospinal fluid (CSF) cultured
Neisseria meningitides. He has a history of 2
such previous presentations which were also
diagnosed as meningococcal meningitis.

Whot is the most likely underlying problem?

1- Hypogammaglobulinaemia

2- HIV infection

3- Recurrent steroid use

4- Macrophage dysfunction

5- Complement deficiency

4- Attention deficit hyperactivity disorder

5- Acute dystonia

Answer & Comments

Answer: 3- Tourette's syndrome

Tourette's syndrome is an inherited
neuropsychiatric disorder with onset in
childhood, characterized by multiple physical
(motor) tics and at least one vocal (phonic) tic;
these tics characteristically wax and wane.

The tics are sudden, repetitive, stereotyped,
nonrhythmic movements (motor tics) and
utterances (phonic tics) that involve discrete
muscle groups.

Answer & Comments

Answer: 5- Complement deficiency

Deficiencies in terminal pathway
complements(C5-C9), particularly C8
complements are implicated in susceptibility
to meningococcal infection.

The lack of membrane attack complex
formation results in severe recurrent infection
by Neisseria gonorrhoeae or Neisseria
meningitidis.

[Q: 2351] MRCPass - 2011
September

An 18 year old man has had longstanding
symptoms of vocal and motor tics. He
displayed peculiar physical tics as well as
repetitive throat clearings-despite the fact
that he rarely had mucus or anything else
bothering his throat. His physical tics
consisted mainly of accentuated blinking and
clenching/extending movements of the hands
and sometimes feet.

What is the diagnosis?

1- Wallenberg's syndrome

2- Huntington's disease

3- Tourette's syndrome

Motor tics are movement-based tics, while
phonic tics are involuntary sounds produced
by moving air through the nose, mouth, or
throat. In the above case, the patient has
hemifacial spasms causing blinking and
athetoid movements of the hands and feet.

[Q: 2352] MRCPass-2011
September

A 55-year-old man presented with a 10 -year
history of an intermittent rash and pruritus
associated with sw eating from exertion. For 2
years he had noted pruritus and erythema
mainly in the hands and feet, occurring on
exposure to cool weather and resolving
promptly on warming. He has a past medical
history of Investigations showed a normal full
blood count and mildly deranged liver
function tests. Cryoglobulin levels were
elevated.

Which one of the following is likely to be a
cause?

1- Hepatitis C

2- Staph aureus pneumonia

3- Colorectal carcinoma

4- Breast carcinoma

5- Osteoarthritis

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Answer & Comments

Answer: 1- Hepatitis C

Cryoglobulinaemia occurs when there are
large amount of proteins that become
insoluble at reduced temperatures.

Type I is most commonly encountered in
patients with multiple myeloma.Types II and
III are strongly associated with infection by the
hepatitis C virus.

frontal lobe had infarcted acutely.

Which one of the following is a test of frontal
lobe dysfunction?

1- Inability to draw a clock face

2- Inability to generate a list rapidly

3- Intention tremor with finger nose testing

4- Sensory inattention

5- Visual field defects

Types II and III have Rheumatoid Factor
activity and bind to polyclonal
immunoglobulins.

Cryoglobulins may also be present in
mycoplasma pneumonia, leukemias, primary
macroglobulinemia, and some autoimmune
diseases, such as systemic lupus
erythematosus and rheumatoid arthritis.

B-type natriuretic peptide (BNP) is used as a
serum marker for cardiac failure.

Where is it predominantly secreted from?

1- Kidney

2- Liver

3- Brain

[Q: 2353] MRCPass - 2011
September

Answer & Comments

Answer: 2- Inability to generate a list rapidly

An inability to draw a clock face is associated
with constructional apraxia in parietal lobe
damage.

A failure to generate a list rapidly is a test of
frontal lobe (e.g. name animals in 60 seconds
with words beginning from letter F etc).
Intention tremor is a cerebellar sign

Sensory inattention is a manifestation of
parietal lobe dysfunction.

Visual field defect is a manifestation of
occipital lobe (homonymous hemianopia),
temporal lobe (superior quantranopia) or
parietal lobe (inferior quantranopia)
pathology.

4- Cardiac ventricle

5- Pancreas

Answer & Comments

Answer: 4- Cardiac ventricle

BNP is secreted mainly from the left ventricle
in normal adult humans (as well as in patients
with left ventricular dysfunction), whilst ANP
is secreted from atria.

[Q: 2354] MRCPass - 2011
September

A 60-year-old male presents with a stroke and
the CT scan shows a large territory of the

[Q: 2355] MRCPass-2011
September

A 66 year old man presents with a three
month history of fever, malaise, anorexia,
twenty-five pound weight loss, diffuse
myalgias and night sweats, and more recently
hemoptysis. He had a past medical history of
hypertension, and described episodes of
haematuria. Physical examination showed
that he had diffuse lower extremity muscle
tenderness, crepitations in the lungs and a
rash on the trunks. Chest x-ray showed
bilateral diffuse pulmonary infiltrates and also
2 areas of cavitation.

Investigations showed:

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urine protein 1+

urine sediment - many red blood cell and
granular casts

sodium 135 mmol/l

potassium 5.2 mmol/l

urea 14 mmol/l

creatinine 220 [imol/l

What investigation should be organised next?

1- Urine culture

2- Anti neutrophil cytoplasmic antibody

3- Renal biopsy

4- CT of kidney, ureter, bladder

5- MR angiogram of the kidneys

Answer & Comments

Answer: 2- Anti neutrophil cytoplasmic
antibody

The diagnosis fits a pulmonary renal syndrome
such as Wegener's, Churg Strauss or
Goodpasture's syndrome.

Apart from renal failure, there may be
pulmonary haemorrhage, haemoptysis,
infiltrates on the CXR as well as cavitation.

The least invasive method initially to confirm a
vasculitis is to request an ANCA.

2- Tacrolimus

3- Azathioprine

4- Hydroxychloroquine

5- PUVA therapy

Answer & Comments

Answer: 4- Hydroxychloroquine

Discoid lupus erythematosus (DLE) is a
chronic, scarring, atrophy producing,
photosensitive dermatosis.

DLE may occur in patients with systemic lupus
erythematosus (SLE). Skin lesions are typically
localized above the neck, with favored sites
being the scalp, bridge of nose, cheeks, lower
lip, and ears. The primary lesion is an
erythematous papule or plaque with slight-to-
moderate scaling. As the lesion progresses,
the scale may thicken and become adherent,
and pigmentary changes may develop, with
hypopigmentation in the central or inactive
area and hyperpigmentation at the active
border.

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[Q: 2356] MRCPass - 2011

1 ? 1

[Q: 2357] MRCPass-2011

• l 1

September

•u

_ y

September

A 47 year old lady presented to her GP with
lesions in skin that were circular with an
erythematous raised rim with central atrophy.
There was scaliness, follicular plugging, and
telangiectasia over the scalp, ears and face.

This was confirmed to be discoid lupus by the
dermatologist and she has been tried on
betnovate steroid topical treatment but has
not improved.

A 41 year old lady has been seen for
symptoms of joint stiffness, sw elling and
pains. On examination, she has features of
wrist subluxation, ulnar deviation of her hands
and rheumatoid nodules. She is investigated
with X rays of her hand.

Which one of the following features is
expected in rheumatoid arthritis?

1- Subchondral sclerosis

What should be used next?
1- Diprobase cream

2- Marginal osteophyte formation

3- Subchondral cyst

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4- Periarticular osteopenia

5- Compression fractures

Answer & Comments

Answer: 4- Periarticular osteopenia

Findings on XRay consistent with
Rheumatoid Arthritis are:

Narrowing of joint space

■ Periarticular osteopenia
Juxtaarticular bony Erosions
Subluxation and gross deformity
Periarticular soft tissue sw elling

- XRay Findings in Osteoarthritis

■ Non-uniform narrowing of joint space

■ Subchondral bony sclerosis
Marginal osteophyte formation
Subchondral Cyst formation

[Q: 2358] MRCPass-2011
September

A 23 year old male medical student was
brought to hospital by his girlfriend who was
concerned about his behaviour.

He has just returned from a student elective in
the United States. Whilst he was being
assessed he appeared anxious and agitated.
He was restless and paced up and down the
corridor. He spoke very quickly.

Upon questioning, he said that he was doing
extremely well in medicine and soon was to
become the dean of the medical school.

Whot is the most likely diagnosis?

1- Paranoid chizophrenia

2- Anxiety disorder

3- Hypomania

4- Delusional disorder

5- Obsessive compulsive disorder

Answer & Comments

Answer: 3- Hypomania

Hypomania is a mood state characterized by
persistent and pervasive elated or irritable
mood, and thoughts and behaviour that are
consistent with such a mood state.

It is distinguished from mania by the absence
of psychotic symptoms and by its lower
degree of impact on functioning. Patients
often have pressured speech and grandiosity.

There may be flight of ideas, lack of sleep and
inability to slow the mind down.

[Q: 2359] MRCPass-2011
September

A 26 year old woman presents with lethargy,
polyuria and nausea. She has no past medical
history and is currently not taking
medications. Her blood results are: sodium
135 mmol/I, potassium 4.3 mmol/l, urea 7
mmol/l, creatinine 90 pmol/l, calcium 3.2
(2.25-2.7) mmol/l, phosphate 0.3 (0.8-8)
pmol/l, Parathyroid hormone 18 (0.8-8)

pmol/l.

What is the likely cause of hypercaicaemia?

1- Chronic kidney disease

2- Hypophosphataemia

3- Primary hyperparathyroidism

4- 1,25 (OH) vitamin D supplementation

5- Hypocalciuric hypophosphataemic rickets

Answer & Comments

Answer: 3- Primary hyperparathyroidism

The case scenario is consistent with primary
hyperparathyroidism.

PTH enhances active reabsorption of calcium
and magnesium from distal tubules and of the
kidney. As bone is degraded both calcium and
phosphate are released. It also greatly

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increases the excretion of phosphate, with a
net loss in plasma phosphate concentration.

By increasing the calcium:phosphate ratio
more calcium is therefore free in the
circulation.

PTH enhances the absorption of calcium in the
intestine by increasing the production of
activated vitamin D. PTH

up-regulates the enzyme responsible for 1-
alpha hydroxylation of 25-hydroxy vitamin D,
converting vitamin D to its active form (1,25-
dihydroxy vitamin D).

PTH stimulates bone resorption by
osteoclasts.

[Q: 2361] MRCPass - 2011
September

A 56 year old man with insulin dependent
diabetes has routine follow up in the clinic. On
examination, neovascularization was found on
fundoscopy. Blood pressure was 146/92mm
Hg.

What is the treatment of choice?

1- Better glycaemic control

2- Follow up after 3 months

3- Photocoagulation

4- Better pressure control

5- Statin

[Q: 2360] MRCPass - 2011
September

A 71 year old man has a diagnosis of non small
cell lung tumour, and has completed a set of
investigations.

Which one of the following is a
controindicotion to lung surgery?

1- FEV1 of 1.7 L (50% predicted)

2- Horner's syndrome

3- History of myocardial infarction

4- Hypercalcaemia

5- Peripheral neuropathy

Answer & Comments

Answer: 2- Horner's syndrome

An FEV1 of < 1.1 L is a contraindication for
most cardiothoracic surgical procedures.

A malignant pleural effusion, distant
metastases, contralateral mediastinal lymph
node spread, vocal cord paralysis, phrenic
nerve paralysis, Horner's syndrome, and SVC
syndrome are contraindications to surgery in
lung cancer.

Answer & Comments

Answer: 3- Photocoagulation

Treatment is directed at regressing
neovascularisation using Argon laser pan-
retinal photocoagulation.

The new vessels themselves are not targeted
but photocoagulation is spread over a wide
area in order to destroy ischaemic retina and
remove the vasoproliferative stimulus. There
is variable visual loss and night blindness.

[Q: 2362] MRCPass-2011
September

A 56 year old lady has known mitral valve
stenosis from rheumatic heart disease. She
presents with new symptoms of
breathlessness.

Upon examination, which one of the following
signs would suggest that she has mitral
regurgitation?

1- Displaced apex beat

2- Early diastolic murmur in the pulmonary
area

3- Right ventricular heave

4- V wave seen with the JVP

5- Opening snap

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Answer & Comments

Answer: 1- Displaced apex beat

In mitral stenosis, the apex beat is classically
tapping in nature and not displaced.

pyrexial at 38 C. Breath sounds are clear and
there is mild tenderness in the lower
abdomen. There was no focal neurological
signs.

Blood tests reveal :

[Q: 2363] MRCPass-2011
September

A 30 year old woman has been investigated
for hypertension and weight gain. The 25 hour
urine cortisol and dexamethasone suppression
tests confirm significant Cushing's syndrome
with excessively high cortisol levels.

Which one of the following is the most like
odd bose finding?

1- Respiratory acidosis

2- Respiratory alkalosis

3- Metabolic alkalosis

4- Metabolic acidosis

5- Neutral pH

Answer & Comments

Answer: 3- Metabolic alkalosis

With severe hypercortisolism, hypokalemic
metabolic alkalosis may occur.

Hypokalemic metabolic alkalosis may occur in
patients with urinary free cortisol (UFC) levels
higher than 1500 mcg/24-h.

[Q: 2364] MRCPass-2011
September

A 66-year-old female is brought to A&E by her
family, who are concerned about her
increasing confusion over the past 2 days.
There is a history of diarrhea in the preceding
few days. On examination she is found to be

Hb 9.6 g/dl
WCC 12 x 10 9 /l
Platelets 65 x 10 9 /l
sodium 138 mmol/l
potassium 4.7 mmol/l
Urea 18.1 mmol/l
Creatinine 210 pmol/l

A blood film shows schistocytes and
thrombocytopenia.

Whot is the most likely diagnosis?

1- Wegener's granulomatosis

2- Thrombotic thrombocytopenic purpura

3- Goodpasture's disease

4- Idiopathic thrombocytopenic purpura

5- Rapidly progressive glomerulonephritis

Answer & Comments

Answer: 2- Thrombotic thrombocytopenic
purpura

Thrombotic thrombocytopenic purpura (TTP),
involvement of the CNS predominates in TTP
(neurological signs) whilst in HUS there is
mainly renal involvement.

Most cases of TTP arise from inhibition of the
enzyme ADAMTS13, a metalloprotease
responsible for cleaving large multimers of
von Willebrand factor (vWF) into smaller
units.

Neurologic symptoms (confusion, headaches,
stroke), low platelet count, renal impairment
and microangiopathic haemolytic anaemia are
present.

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[Q: 2365] MRCPass-2011
September

A 36 year old lady upper middle class white
lady who used to be an athlete has been
referred for investigation due to tiredness.
She mentions fatigue which is chronic and
occurs even after minor physical work. This
has been going on for 3 years. Investigations
including CK, ESR, EMGs and muscle biopsy
have revealed no obvious medical cause for
this.

Which of the following is the best treatment?

1- Erythropoietin injection

2- Cognitive behavioural therapy

3- Graded exercise programme

4- Codeine

5- Fluoxetine

Answer & Comments

Answer: 3- Graded exercise programme

Chronic Fatigue syndrome is defined by
symptoms and not signs.

The clinical profile of an individual with CFS is
of a high-achieving student or athlete who
usually is female (80%), white, and middle-
class to upper middle-class.

Treatment is largely supportive and
responsive to symptomatology. This includes
physical therapy and modest aerobic or
anaerobic exercise (if possible) to avoid
cardiovascular deconditioning. Sleep may be
addressed with medication; often, melatonin
or night-time amitriptyline is helpful. If
present and severe, pain often is addressed in
a pain clinic.

L2J

A 50 year-old woman developed symptoms
decreased sleep and increased anxiety over 2
months. She was constantly worried about

[Q: 2366] MRCPass-2011
September

contracting bird flu. Although there was no
epidemic at the moment, she refused to go
out to the garden to collect the washing as she
felt that there were birds which would cause
flu transmission.

Her husband witnessed that she was hearing
voices when there was no one speaking.

What is the diagnosis?

1- Mania

2- Psychotic depression

3- Paranoid schizophrenia

4- Conversion disorder

5- Anxiety disorder

Answer & Comments

Answer: 3- Paranoid schizophrenia

This lady has delusions and paranoid
symptoms consistent with paranoid
schizophrenia.

Schizophrenia most commonly manifests as
auditory hallucinations, paranoid or bizarre
delusions, or disorganized speech and
thinking, and it is accompanied by significant
social or occupational dysfunction. . Delusions
are persecutory and/or grandiose, but in
addition to these, other themes such as
jealousy, religiosity, or somatization may also
be present.

A 46-year-old woman presented with a chief
complaint of heavy smoking and a desire to
quit. She has a history of diabetes,
hypertension, migraines and epilepsy. The
patient's social histories revealed a 3 pack per
year smoking history, minimal alcohol use,
and no elicit drug use. Given her desire to quit
smoking, the patient planned to be started on
bupropion 100 mg daily for 1 week, with goal
titration to 150 mg twice daily by the end of
week.

[Q: 2367] MRCPass-2011
September

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Which one of the following is o
contraindication ?

1- Diabetes

2- Hypertension

3- Ischaemic heart disease

4- Epilepsy

5- Migraines

Answer & Comments

Answer: 4- Epilepsy

Buproprion is an atypical antidepressant that
acts as a norepinephrine and dopamine
reuptake inhibitor, and nicotinic antagonist.

Initially researched and marketed as an
antidepressant, bupropion was subsequently
found to be effective as a smoking cessation
aid.

What is the likely diagnosis?

1- Chronic myeloid leukaemia

2- Essential thrombocythaemia

3- Myelofibrosis

4- Multiple myeloma

5- Waldenstrom's macroglobulinaemia

Answer & Comments

Answer: 3- Myelofibrosis

Myelofibrosis is a chronic, progressive
myeloproliferative disease.

The manufacturers, GSK, advises that
bupropion should not be prescribed to
individuals with epilepsy or other conditions
that lower the seizure threshold, such as
alcohol or benzodiazepine discontinuation.

[Q: 2368] MRCPass-2011
September

A 36-year old man was referred with a two-
month history of generalised weakness, fever,
and weight loss.

Blood results showed:

Hb was 9 g/dl

haematocrit was 18%

white cell count 5.3 x 10 9 /l

platelet count was 89 x 10 9 /I

His reticulocyte count was <0.0001%.

It is characterised by prominent bone marrow
stromal reaction including collagen fibrosis
and osteosclerosis.

[Q: 2369] MRCPass-2011
September

A 14 year old male patient has long standing
history of difficulty gaining weight, polyuria
and recurrent infections.

On examination, he had a blood pressure of
120 / 70 mmHg, abdomen was soft, non
tender and there were no localizing signs on
neurological examination. Investigations
showed a metabolic alkalosis. The patient was
diagnosed with Bartter's syndrome.

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What other abnormality is likely to be present?

1- Hyponatraemia

2- Hypernatraemia

3- Hypokalaemia

4- Hyperchloraemia

5- Hypermagnesaemia

Answer & Comments

Answer: 3- Hypokalaemia

The clues here are hypokalaemia and normal
blood pressure pointing tow ards Bartter's
syndrome.

Both Conn's and Cushing's syndrome are
associated with hypertension. Bartter's
syndrome (autosomal recessive) is an
inherited renal tubular disorder characterized
by hypokalemia, hypochloremic metabolic
alkalosis, hyperreninemia,

hyperprostaglandinism, normal blood
pressure, with increased urinary loss of
sodium, chloride, potassium, calcium.

Vomiting, diarrhoea polyuria and poor growth
are presenting symptoms.

Different forms of renal tubular defects are
found in Bartter's syndrome, and the Na-K-2CI
transporter is a common defect. Failure to
reabsorb chloride results in a failure to
reabsorb sodium and leads to excessive
sodium and chloride (salt) delivery to the
distal tubules, leading to excessive salt
(including calcium) and water loss from the
body. The renin-angiotensin-aldosterone
system is activated due to hypovolaemic state,
but helps to maintain a normal blood
pressure.

[Q: 2370] MRCPass - 2011
September

A 20 year-old man presents with facial and
ankle sw elling which has slow ly been
developing over the past 2 weeks. There were
no urinary symptoms and no family history of

renal disease. On examination, he was pale
and thin with ankle oedema and a blood
pressure of 130/80.

Investigations showed normal haemoglobin
and white cell count and an erythrocyte
sedimentation rate (ESR) of 32mm/hr. His
blood urea was 9.1mmol/l (2.5-7.5), serum
albumin 26g/l and a creatinine clearance of
106ml/min.

His serum immunoglobulin IgM and IgA, C3
and C4 levels were normal. Antinuclear
antibodies and hepatitis B surface antigen
were not detected, and the antistreptolysin O
titre was not raised. A urine dipstick shows
protein ++++ and 24 hour urine collection
demonstrated urinary protein loss of
7.8g/day.

What is the most likely cause of this
presentation?

1- IgA nephropathy

2- Focal segmental glomerulonephritis

3- Minimal change disease

4- Membranous glomerulonephritis

5- Renal cell carcinoma

Answer & Comments

Answer: 4- Membranous glomerulonephritis

With no haematuria, IgA nephropathy is
unlikely.

The most likely options are minimal change
and membranous. Due to the age of
presentation, membranous

glomerulonephritis is the best answer.

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Focal segmental glomerulonephritis is a
possibility for nephrotic presentation but is
often associated with HIV and malignancy, and
less common.

[Q: 2371] MRCPass - 2011
September

A 35 year old lady has a past history of two
episodes of deep vein thombosis and two
miscarriages. During investigation she was
found to have positive anti cardiolipin
antibody.

What is the best treatment?

1- Clopidogrel

2- Warfarin 3 months

3- Long term low molecular weight heparin

4- Aspirin and Warfarin

5- Lifelong warfarin

Answer & Comments

Answer: 5- Lifelong warfarin

Which one of the following drugs is
contraindicated for use with sildenafil?

1- Doxazosin

2- Aspirin

3- Nicorandil

4- Atenolol

5- Ramipril

Answer & Comments

Answer: 3- Nicorandil

The combination of nitrates (and drugs such
as nicorandil) with sildenafil is
contraindicated.

This combination must be avoided as it can
produce significant hypotension and is
potentially fatal.

[Q: 2373] MRCPass-2011
September

A 18-year-old man presented casualty
complaining of difficulty breathing. He had
brought hospital by ambulance, having
collapsed shortly after being stung on hand by
a bee. On examination, his blood pressure was
80/40 mmHg, facial sw elling and pharyngeal
oedema was noted.

Which one of following investigations likely
confirm anaphylaxis?

1- Haemolytic complement (CH50) level

2- Serum tryptase activity

This patient with recurrent DVTs has the
presence of lupus anticoagulant.

She requires lifelong warfarin treatment.

3- Complement C3 level

4- Total IgE level

5- Eosinophil count

[Q: 2372] MRCPass-2011
September

A 51-year-old man who had a large myocardial
infarction of the anterior wall 20 years ago is
on several cardiac medications.

Answer & Comments

Answer: 2- Serum tryptase activity

The reaction involves preferential production
of IgE, in response certain antigens, which in
turn initiates a sequence of events leading to
mast cell activation.

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According to the Resuscitation council
guidelines, the specific test to help confirm a
diagnosis of an anaphylactic reaction is
measurement of mast cell tryptase.

Tryptase is the major protein component of
mast cell secretory granules. In anaphylaxis,
mast cell degranulation leads to markedly
increased blood tryptase concentrations
(Figure 4). Tryptase levels are useful in the
follow -up of suspected anaphylactic
reactions, not in the initial recognition and
treatment: measuring tryptase levels must not
delay initial resuscitation. Tryptase
concentrations in the blood may not increase
significantly until 30 minutes or more after the
onset of symptoms, and peak 1-2 hours after
onset.

The half-life of tryptase is short
(approximately 2 hours), and concentrations
may be back to normal within 6-8 hours, so
timing of any blood samples is very important.

http://www.resus.org.uk/pages/reaction.pdf

[Q: 2374] MRCPass-2011
September

A 41 year old patient with previous tonic
clonic seizures is on sodium valproate 400mg
bd.

Which of the following is a common side-effect
of sodium valproate?

1- Gum hypertrophy

2- Weight loss

3- Hirsutism

4- Tremor

5- Thrombocytosis

Answer & Comments

Answer: 4- Tremor

Side effects of sodium valproate are tremor,
weight gain, transient hair loss and
thrombocytopenia.

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*+ [ Q: 2375 ] MRCPass - 2012 January

/ -

# A 55 year old man was brought to
the A&E with sw elling of the face
bronchospasm and urticaria after he took
some unknown food items.

On examination Blood pressure is 90/60mm
of Hg. He gave a past history of food allergy.

What is the route of administration of
adrenaline which should be given?

3- Penicillin

4- Linezolid

5- Ceftazidime

Answer & Comments

Answer: 2- Vancomycin

This is a case of septic discitis (infection of the
spinal disc) due to staphylococcus.

1- Intravenous

2- Intramuscular

3- Subcutaneous

4- Oral

5- Inhaled

Answer & Comments

Answer: 2- Intramuscular

Adrenaline 1 ml of a 1:1000 solution (1 mg)
should be injected intramuscularly to treat
anaphylaxis.

[ Q: 2376 ] MRCPass - 2012 January

A 40-year-old man was admitted
with acute-onset lower back.

On examination he was pyrexial. He had
restricted lumbar spine movement with pain
at this site. He is currently on
antihypertensive drugs and is allergic to
penicillin.

Back pain, fever and neurological signs are
often present in septic discitis. 40% of cases
are due to staph aureus, and blood cultures
are often positive. MRI of the spine will help
to confirm the diagnosis. Treatment options
include vancomycin, gentamicin and
ceftazidime. The best first line option here
would be vancomycin.

[ Q: 2377 ] MRCPass - 2012 January

A 65-year-old man is brought to
A&E by his family, who are concerned him
being tired and unwell. He has a previous
history of myocardial infarction. He takes
ramipril and bendrofluazide tablets. There
was a history of diarrhea in the preceding few
days. On examination his breath sounds are
clear and there is mild tenderness in the
lower abdomen.

Blood tests reveal :

Hb 9.4 g/dl

WCC 12 x 10 9 /l

Investigations showed a white cell count of

22.0x1071 (4.0-11.0x1071), urea 8.0 mmol/l

(2.5-7.5 mmol/l), creatinine of 160 [imol/l
(60-120 pmol/l), erythrocyte sedimentation
rate (ESR) of 108 mm/h and CRP of 210 mg/I
(<20 mg/I).

Blood cultures grew Methicillin sensitive
staph aureus.

What antibiotics should be commenced?

1- Clarithromycin

2- Vancomycin

Platelets 65 x 1071

sodium 138 mmol/l

potassium 4.7 mmol/l

Urea 23.1 mmol/l

Creatinine 366 pmol/l

What is the blood film likely to show ?

1- Target cells

2- Howell jolly body

3- Red cell casts

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4- Fragmented red blood cells

5- Spherocytes

Answer & Comments

Answer: 4- Fragmented red blood cells

The diagnosis is Hemolytic uremic syndrome
(HUS).

It is characterized by the triad of
microangiopathic hemolytic anemia,
thrombocytopenia, and acute renal failure.
Diarrhea and upper respiratory infection are
the most common precipitating factors. The
most common cause of HUS is a toxin
produced by Escherichia coli serotype
0157:H7.

Additional agents include Shigella,
Salmonella, Yersinia, and Campylobacter
species.

Although the vascular lesions are identical in
HUS and Thrombotic thrombocytopenic
purpura (TTP), involvement of the CNS
predominates in TTP (neurological signs)
whilst in HUS there is mainly renal
involvement.

The hallmark of HUS in the peripheral smear
is the presence of schistocytes. These consist
of fragmented, deformed, irregular, or
helmet-shaped RBCs

[ Q: 2378 ] MRCPass - 2012 January

A 22 year old woman presents
bilateral leg weakness following an episode of
diarrhoea 2 weeks ago. She is suspected of
having Guillain-Barre syndrome.

Which of the following test results is likely on
the neurological tests?

1- Fibrillations on the EMG

2- Slow conduction velocities in the nerve
conduction study

3- Decreased visual evoked potential

4- Increased amplitude in the nerve

conduction study

5- Shortened latencies in the nerve

conduction study

Answer & Comments

Answer: 2- Slow conduction velocities in the
nerve conduction study

In Guillain Barre syndrome, Electromyography
(EMG) and nerve conduction studies (NCS)
may show prolonged distal latencies,
conduction slowing, conduction block, and
temporal dispersion of compound action
potential in demyelinating cases.

[ Q: 2379 ] MRCPass - 2012 January

A 23 year old man with learning
difficulties is brought for review by his
worried parents after he complained of visual
blurring.

Examination with a slit lamp reveals ectopia
lentis.

What is the most likely diagnosis?

1- Marfan's syndrome

2- Klinefelter's syndrome

3- Ehler Danlos

4- Homocystinuria

5- Fragile X syndrome

Answer & Comments

Answer: 4- Homocystinuria

Ectopia lentis/ subluxation of the lens is
associated with Ehlers Danlos syndrome,
Marfan's syndrome and homocystinuria.

There is downwards lens dislocation in
homocystinuria.

[ Q: 2380 ] MRCPass - 2012 January

A 62 year old lady presented with a
fall and fractured writst. She was organised to

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have a DEXA scan. This showed a T score of -
2.6 in the hip and a score of -2.1 in the femur.

What does this mean?

1- Normal values on the scan

2- osteopenia of the hip and osteoporosis of
the femur

3- Osteoporosis of the hip and osteopenia of
the femur

4- Osteopenia of both areas

5- Osteoporosis of both areas

Answer & Comments

Answer: 3- Osteoporosis of the hip and
osteopenia of the femur

The T score is usually used to make treatment
decisions using standard deviation (SD).

potassium 2.4 mmol/l,

calcium 1.6 (2.25-2.7) mmol/l

phosphate 0.8 (0.8-8) pmol/l,

chloride 86 (95-107) mmol/l

bicarbonate 33 (20-28) mmol/l

What other abnormality is likely to be found?

1- Hyperthyroidism

2- Hyperaldosteronism

3- Hypoglycaemia

4- Hyperlipidaemia

5- Hypomagnesaemia

Answer & Comments

Answer: 5- Hypomagnesaemia

The laboratory findings of hypokalaemia,
hypocalcaemia, hypomagnesaemia and
metabolic alkalosis can occur in severe
alcoholic patients.

Correction of these electrolyte abnormalities
with cautious refeeding is important.

A T score between 0 and -1 standard
deviation (SD) is considered to be normal.

A T score between -1 and -2.5 SD is classified
as osteopenia (low bone mass).

[ Q: 2382 ] MRCPass - 2012 January

A 43-year-old woman is found to be
hypertensive but referred by the GP due to
poorly controlled hypertension.

A T score of -2.5 SD or less is classified as
osteoporosis (very low bone mass).

^ [ Q: 2381 ] MRCPass - 2012 January

/ -

# A 58-year-old Caucasian male

presents with weight loss and severe
muscular weakness. He was a heavy smoker
and drinks 20 units of alcohol per day. His
medical history included hypertension and
gastrointestinal reflux. On examination, he
had a blood pressure of 120 / 70 mmHg,
abdomen was soft, non tender.

Investigations showed:

sodium 136 mmol/l

The patient received 3 antihypertensive
medications including a beta-blocker, diuretic
and a calcium channel blocker. Her blood
pressure is consistenly above 150 mmHg
systolic. There is no family history of
hypertension.

Her renal function is normal but urine dipstick
testing shows + blood. A renal ultrasound
shows kidney sizes of 7.5 in the right and 7
cm in the left.

What is the most likely cause of this patient's
hypertension ?

1- Autosomal dominant polycystic kidney
disease

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2- Conn's syndrome

3- Essential hypertension

4- Fibromuscular dysplasia

5- Cushing's syndrome

Answer & Comments

Answer: 4- Fibromuscular dysplasia

Fibromuscular dysplasia (FMD) is a
nonatherosclerotic angiopathy of unknown
etiology.

4- L5/S1 disc prolapse

5- Common peroneal nerve injury

Answer & Comments

Answer: 4- L5/S1 disc prolapse

Ankle dorsiflexion is generally supplied by
L4/L5 and plantar flexion supplied by S1/S2.

The history of back pain and neurological
signs is consistent with an L5/S1 disc
prolapse.

Medial FMD represents the most common
type and is characterized by the classic "string
of beads" appearance. FMD usually affects
females between 15 and 50 years of age,
frequently involves the mid or/and distal
segments of the renal artery and is bilateral in
2/3 of the patients. Often, hypertension tends
to be refractory to simple drug therapy.

Percutaneous transluminal renal angioplasty
(PTRA) should be considered in well-defined
groups of patients: those with a recent onset
of hypertension (in particular patients
younger than 50 who are less likely to have
underlying atherosclerotic disease) in whom
the goal is to cure the hypertension.

^ [ Q: 2383 ] MRCPass - 2012 January

t - u -

# A 43 year old man presents to A+E
complaining of severe lower back pain
following carpentry work. The pain radiates
to his left buttock and thigh. On examination,
he was able to straight leg raise to 45 degrees
only on the left side. The sciatic stretch test is
positive. He has difficulty plantar flexing his
left ankle and has abnormal sensation on the
plantar aspect of the foot. The left ankle
reflex was difficult to elicit.

What is the diagnosis?

1- Cauda equina syndrome

2- L2/L3 disc prolapse

3- L4/L5 disc prolapse

[ Q: 2384 ] MRCPass - 2012 January

A 55-year-old female presented
with dyspnea, orthopnea, lower extremities
sw elling, palpitations. Physical examination
revealed an irregular pulse 80 beats/min,
blood pressure of 100/60 mmHg and bibasal
crackles on chest auscultation. The jugular
veins were distended and there was evidence
of CV waves. She had a left parasternal heave.
There was a systolic murmur at the upper left
border of the sternum which was louder with
inspiration. The second heart sounds were
fixed, wide and split.

What is the most likely diagnosis?

1- Aortic stenosis

2- Mitral regurgitation

3- Atrial septal defect

4- Pulmonary stenosis

5- Pulmonary regurgitation

Answer & Comments

Answer: 3- Atrial septal defect

In an ASD, there may be an ejection systolic
murmur that is due to the increased flow of
blood through the pulmonic valve rather than
any structural abnormality of the valve
leaflets.

In unaffected individuals, there are
respiratory variations in the splitting of the

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second heart sound (S2). In individuals with
an ASD, there is a fixed splitting of S2.

This does not occur with pulmonary stenosis.
There is also evidence of right heart strain
(tricuspid regurgitation, right ventricular
hypertrophy causing left parasternal heave).

^ [ Q: 2385 ] MRCPass - 2012 January

fi -

# A 35-year-old Caucasian woman
admitted has a history of widespread,
pruritic, erythematous skin rash, joint pains
and renal disease. She recently had a baby
with congenital heart block. Laboratory
investigations revealed mild leucopenia (w
hite cell count 3.25xl09/ml) and
thrombocytopenia (platelets 140xl09/ml).
Erythrocyte sedimention rate was increased
(65 mm/h).

Which antibody is likely to be positive?

1- Anti Jo 1

placenta. These autoantibodies can be found
alone or in combination; However, anti-Ro is
present in almost 95% of patients.

^ [ Q: 2386 ] MRCPass - 2012 January

ft -

* A 30 year old lady presented with
joint pains which has been present for 2 years
but were getting more severe.

After clinical examination, blood tests and x
rays, she has been diagnosed with
rheumatoid arthritis. The rheumatoid factor
was negative. Hand X rays showed osteopenia
and joint erosions.

Which one of the following carries the poorest
prognostic factor?

1- Rheumatoid factor negative

2- Joint erosions

3- Female sex

4- Insidious onset

2- Anti double stranded DNA

5- Age of 30 years

3- Anti Ro

4- Anti centromere

5- ANCA

Answer & Comments

Answer: 3- Anti Ro

The anti Ro antibody is associated with
Sjogren's syndrome, SLE and neonatal lupus.

Neonatal lupus erythematosus (NLE) is a rare
disorder caused by the transplacental passage
of maternal autoantibodies. Only 1% of
infants with positive maternal autoantibodies
develop neonatal lupus erythematosus. The
most common clinical manifestations are
cardiac (congenital heart block), dermatologic
(urticaria and skin desquamation) , and
hepatic (abnormal LFTs). The mother
produces immunoglobulin G (IgG)
autoantibodies against Ro (SSA), La (SSB),
and/or Ul-ribonucleoprotein (Ul-RNP), and
they are passively transported across the

Answer & Comments

Answer: 2- Joint erosions

Poor prognostic factors in Rheumatoid
arthritis include persistent synovitis, early
erosive disease, extra-articular findings
(including subcutaneous rheumatoid
nodules), positive serum RF findings, positive
serum anti-CCP autoantibodies, carrier of
HLA-DR4 alleles, family history of RA, poor
functional status, socioeconomic factors,
elevated acute phase response ESR, CRP, and
increased clinical severity.

[ Q: 2387 ] MRCPass - 2012 January

A 42-year-old man with end-stage
renal disease (ESRD) who was receiving
hemodialysis was admitted with fevers and
rigors.

He has been having dialysis via a tunnelled
subclavian central venous cathether for

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several weeks. The patient was febrile and
had a WBC count of 18 x 10 3 /|iL.

What is the most likely cause of septicaemia
in this patient?

1- Escherichia coli

2- Listeria monocytogenes

3- Staphylococcus aureus

4- Staphylococcus epidermidis

5- Streptococcus pyogenes

Answer & Comments

Answer: 2- Small cell

Small-cell lung cancer accounts for
approximately 20-25% of all cases of lung
cancer.

It is strongly associated with smoking. Small
cell carcinomas produce ACTH and ADH,
which can lead to SIADH, the clue in the
history is hyponatraemia.

Answer & Comments

Answer: 3- Staphylococcus aureus

Staph aureus and pseudomonas are common
organisms causing sepsis in dialysis patients
with central venous lines.

Coagulase negative staph (staph epidermidis)
are common commensal organisms but do
not usually lead to sepsis in these patients.

[ Q: 2389 ] MRCPass - 2012 January

A 20-year-old man presents with
discrete scaly papules affecting his trunk and
upper arms. The eruption developed 2 weeks
after an episode of acute exudative tonsillitis.
He was treated with a course of penicillin for
5 days. On examination, there were small,
drop-like, salmon-pink, 1 mm to 10 mm
papules with a fine scale on the trunk and
arms.

[ Q: 2388 ] MRCPass - 2012 January

Hb 11.5 g/dl, MCV 75 fl, WCC 6 x 10 9 /l,
platelets 200 x 10 9 /l, sodium 125 mmol/l,
potassium 4.5 mmol/l, urea 5 mmol/l,
creatinine 100 |imol/l.

Which one of the following is the most likely
lung cancer in this patient?

1- Squamous cell

What is the diagnosis?

1- Erythema multiforme

2- Secondary syphilis

3- Guttate psoriasis

4- Dermatitis herpetiformis

5- Pityriasis versicolor

Answer & Comments

Answer: 3- Guttate psoriasis

Guttate psoriasis refers to a distinctive, acute
clinical presentation of an eruption
characterized by small, droplike, 1-10 mm in
diameter, salmon-pink papules, usually with a
fine scale.

2- Small cell

3- Adenocarcinoma

4- Large cell

5- Carcinoid

It is more common in individuals younger
than 30 years, a history of upper respiratory
infection secondary to group A beta-
hemolytic streptococci (eg, Streptococcus
pyogenes) often precedes the eruption by 2-3
weeks. Although recurrent episodes may
occur, especially those due to pharyngeal

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carriage of streptococci, isolated bouts are
known to occur. Usually, the psoriasis
spontaneously disappears in a few weeks
without treatment. Simple reassurance and
emollients may be sufficient care.

[ Q: 2390 ] MRCPass - 2012 January

Which one of the following HLA
groups is genetically associated with
rheumatoid arthritis?

1- HLA B27

2- HLA B6

3- HLA DR3

4- HLA DR4

5- HLA A8

Answer & Comments

Answer 4- HLA DR4

Rheumatoid arthritis has a genetic link with
HLA-DR4 and related allotypes of MHC Class II
and the T cell-associated protein PTPN22.

[ Q: 2391 ] MRCPass - 2012 January

A 30 year old woman is admitted to
hospital due to concerns from her relatives
with lack of sleep and agitation.

When giving a history, she says that she is the
Queen of England and continues talking
despite interruption by the doctor.

What is this feature?

1- Circumstantiality

2- Flight of ideas

3- Pressure of speech

4- Paranoia

5- Thought intrusion

Answer & Comments

Answer: 3- Pressure of speech

Patients with mania often have pressured
speech and grandiosity.

There may be flight of ideas, lack of sleep and
inability to slow the mind down. Pressure of
speech is a tendency to speak rapidly and
frenziedly, as if motivated by an urgency not
apparent to the listener.

[ Q: 2392 ] MRCPass - 2012 January

A new blood test is being evaluated
for measuring the likelihood of heart failure
(HF), as compared to echocardiography as a
gold standard. In the study, the following
results are obtained:

Blood test
positive

Blood test
negative

Echo-HF

720

10 "1

Echo - no HF

30 1

f 890

What is the negative predictive value of the
blood test?

1- 30/750

2- 30/780

3- 890/900

4- 890/10

5- 890/30

Answer & Comments

Answer: 3- 890/900

Negative predictive value is the number of
true negatives found by a negative blood test,
in this case, 890 / (890 + 10).

[ Q: 2393 ] MRCPass - 2012 January

A 55 year old man presented with
retrosternal chest pain.

He has history of hypertension and diabetes.

His ECG shows anterior wall myocardial
infarction with ST elevation in leads VI to V4.
He has been given Aspirin, Clopidogrel and

severe

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continues to have chest pains. Tirofibran is
then commenced.

What is tirofibran's mechanism of action?

1- Tissue plasminogen activator

2- Streptokinase

3- Statin

4- Direct Thrombin inhibitor

5- GIIBIIIA inhibitor

Answer & Comments

Answer: 5- GIIBIIIA inhibitor

An unstable patient with coronary arterial
disease can be considered for a GIIBIIIA
inhibitor such as tirofibran whilst awaiting
coronary angiography.

Abxicimab, another GIIBIIIA inhibitor, is also
frequently used prior to angioplasty.

[ Q: 2394 ] MRCPass - 2012 January

Blood tests showed:

Hb 10.5 g/dl, WCC 7 x 10 9 /l, platelets 220 x
10 9 /l, ESR 90 mm/hr, sodium 135 mmol/I,
potassium 4.2 mmol/l, urea 16 mmol/I,
creatinine 240 pmol/l, calcium 2.9 (2.25-2.7)
mmol/l, phosphate 0.6 (0.8-8) pmol/l. IgA 3.2
(0.5-4.0) g/l , IgG 23 (5.0-13.0) g/l, IgM 2.3
(0.3-2.2) g/l.

Routine urine examination showed urine
albumin trace, urine protein/creatinine ratio
2.7 and urinary Bence Jones protein was
positive.

What is the likely diagnosis?

1- Waldenstrom's macroglobulinaemia

2- Multiple myeloma

3- Chronic myeloid leukaemia

4- Acute lymphocytic leukaemia

5- Osteoporosis

Answer & Comments

Answer: 2- Multiple myeloma

The presence of unexplained anemia, kidney
dysfunction, a high erythrocyte
sedimentation rate (ESR), hypercalcaemia and
a high serum paraprotein with bence jones
proteinuria suggests multiple myeloma.

^ [ Q: 2395 ] MRCPass - 2012 January

/ --—

* A 30 year old female took 40 tablets
of Paracetamol and was admitted to hospital.

She is seen the following day and needs
assessment of her medical condition.

Which of the following is the best
investigation to assess prognosis after 26
hours for a paracetamol overdose?

1- Prothrombin time

2- AST

3- Paracetamol level

4- Urea and creatinine

5- Bilirubin

Answer & Comments

Answer: 1- Prothrombin time

Although all of the tests may be abnormal,
the INR / prothrombin time measurement is
the most important in predicting prognosis
(part of the child pugh criteria for liver failure)
after a paracetamol overdose.

[ Q: 2396 ] MRCPass - 2012 January
A 70 year old man presents with a

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history of breathlessness.

He has a past medical history of hypertension
and a myocardial infarction 5 years ago. He
smokes 20 cigarettes and drinks 2 units of
alcohol per day. On examination, BP was
120/70, 02 sats 95% on air. Cardiovascular
and respiratory examination was
unremarkable.

Neurological examination revealed a right
sided eye ptosis and miosis. Eye movements
were normal.

What investigation should be done to confirm
the diagnosis?

1- MRI of the brain

2- Chest X ray

3- ECG

4- Fundoscopy

5- CT scan of the abdomen

Answer & Comments

Answer: 2- Chest X ray

This patient who is a heavy smoker also has
signs of horner's syndrome on the right side.

This suggests a possible Pancoast tumour of
the lung. A space occupying lesion, a brain
stem CVA, trauma to the neck and also
Pancoasts' tumour may all cause Horner's
syndrome.

^ [ Q: 2397 ] MRCPass - 2012 January

# I

Which ion / channel is primarily
responsible for repolarisation phase in the
cardiac cells?

1- Sodium

2- Calcium

3- Phosphate

4- Magnesium

5- Potassium

Answer & Comments

Answer: 5- Potassium

Depolarisation and repolarisation refer to
neuronal conduction or cardiac electrical
activity.

[ Q: 2398 ] MRCPass - 2012 January

A 32 year old woman has presented
with recurrent sinusitis and symptoms of
haemoptysis for 6 months. Urine dipstick
showed blood ++ and she was noted to have
renal impairment with a creatinine of 160
umol/l. A Chest XR showed upper lobe
infiltrates.

Investigations showed:

urine sediment - many red blood cell and
granular casts

erythrocyte sedimentation rate (ESR) was 50
mm/hr

anti-nuclear antibody (ANA) - borderline
positive 1:40

anti-streptolysin O (ASO) antibody -< 1:40

c-ANCA - positive at a titer of 1:320, PR 3
positive

p - ANCA - negative

What is a renal biopsy likely to show ?

1- Crescentic glomerulonephritis

2- Minimal change glomerulonephritis

3- IgA nephropathy

4- Post streptococcal glomerulonephritis

5- Goodpasture's syndrome

Answer & Comments

Answer: 1- Crescentic glomerulonephritis

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Crescentic glomeurloneprhtis, also known as
Rapidly progressive glomerulonephritis
(RPGN) is characterized by a rapid loss of
renal function, (usually a 50% decline in the
glomerular filtration rate (GFR) within 3
months) with glomerular crescent formation
seen in at least 50% of glomeruli seen on
kidney biopsies.

In 50% of cases, RPGN is associated with an
underlying disease such as Goodpasture
syndrome, systemic lupus erythematosus, or
Wegener granulomatosis; the remaining
cases are idiopathic. Regardless of the
underlying cause, RPGN involves severe injury
to the kidneys' glomeruli, with many of the
glomeruli containing characteristic glomerular
crescents (crescent-shaped scars).

[ Q: 2399 ] MRCPass - 2012 January

A 30 year old man has been on a
recent trip on a holiday visiting his family. He
has not previously been immunized with BCG.
He now feels unwell with fevers and lethargy
but did not have a productive cough. He also
mentioned he was recently in contact with a
friend who had active tuberculosis infection
confirmed through positive sputum culture.

What should be done for him now?

1- Mantoux test

2- Quantiferon test

3- BCG immunisation

4- Isoniazid prophylaxis

5- Start quadruple TB therapy

Answer & Comments

Answer: 1- Mantoux test

intradermal injection of tuberculin purified
protein derivative (PPD). If the mantoux test
showed a strongly positive response then the
patient is likely to have active tuberculosis
and will need treatment. The best diagnostic
tool in suspected pulmonary TB is sputum
stain for AFB but this patient does not have a
productive cough. A quantiferon test is a
blood test which is helpful but can be non
specific and should not be used as a primary
diagnostic tool.

[ Q: 2400 ] MRCPass - 2012 January

A 55 year woman presents with a
red eye on the left. It only began last night
and she complained of pain and blurred
vision. On examination, there was left corneal
edema, and dilated pupils.

Which one of the following is most likely?

1- Central retinal vein occlusion

2- Closed angle glaucoma

3- Vitreous haemorrhage

4- Partial retinal detachment

5- Cataract

Answer & Comments

Answer: 2- Closed angle glaucoma

In acute closed angle glaucoma, intra-ocular
pressure is increased as a result of an
impairment of aqueous outflow.

The closure is due to contact of the peripheral
iris with the trabecular meshw ork at the
entrance to Schlemm's canal.

The commonest presentation is with a red
eye.

As this patient has not been previously
immunised, a mantoux text is helpful because
it is likely to be negative if he did not have TB
infection.

The Mantoux Test (MT) is a classical delayed-
type hypersensitivity (DTH) response to the

[ Q: 2401 ] MRCPass - 2012 January

A 46 year old man is known to have
ulcerative colitis which was diagnosed 10
years ago. Over the last two months he has
right upper quadrant discomfort and noticed

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to have jaundice. He was referred to the
gastroenterology outpatients for assessment.
Investigations performed showed these
results: Ultrasound showed a dilated intra
and extrahepatic ducts with beaded
appearances. Blood tests results:

ALT 120 (5-35) U/l

AST 90(1-31) U/l

ALP 750 (20-120) U/l

Bilirubin 80 (1-22) pmol/l

Albumin 38 (37-49) g/l

amylase 250 (60-180) U/l

What test should be done to confirm the
diagnosis?

1- Chest X Ray

2- OGD

3- CT scan of abdomen

4- Gamma GT

5- Magnetic resonance

cholangiopancreatography

Answer & Comments

Answer: 5- Magnetic resonance

cholangiopancreatography

The cholestatic picture along with
inflammatory lesion seen on the ultrasound
hints tow ards either Sclerosing cholangitis or
associated with ulcerative colitis.

Narrowing of the bile duct lumen usually
occurs throughout the biliary tree. Less
commonly, changes are confined to the intra-
hepatic or extra-hepatic ducts. Primary
sclerosing cholangitis is a rare disease of
unknown aetiology characterised by chronic
inflammation and fibrosis of the bile duct.
Primary sclerosing cholangitis is associated
with cholangiocarcinoma, a cancer of the
biliary tree, and the lifetime risk for PSC
sufferers is 10-15%. As many as 5% of
patients with ulcerative colitis may progress
to develop primary sclerosing cholangitis.

The diagnosis is by imaging of the bile duct,
usually in the setting of endoscopic
retrograde cholangiopancreatography (ERCP)
which shows "beading" (both strictures and
dilation) of the intrahepatic and extrahepatic
bile ducts. Another option is magnetic
resonance cholangiopancreatography

(MRCP), where magnetic resonance imaging
is used to visualise the biliary tract.

[ Q: 2402 ] MRCPass - 2012 January

A 56-year-old, unemployed, man
was admitted due to confusion and
disorientation with the onset of acute
symptoms a few days before admission. He
had a history of alcohol dependence of 20
years duration. He was aw ake but
disorientated to person, location, situation,
and time.

Temperature was 36.5 °C and BP was 120/80
mmHg. Neurological examination revealed
gaze-evoked nystagmus in all directions. All
deep tendon reflexes were normal. The
finger-nose test was ataxic. Standing and gait
with open eyes evidenced a distinct ataxia
with tremors of the upper extremity. The
Romberg sign was positive. He had an MMSE
score of 26 /30 on admission. A blood glucose
measurement was 3 mmol/I.

What should be given to treat the patient?

1- 50 ml of 50% dextrose

2- 500 mis of 5% dextrose

3- Thiamine infusion

4- Lactulose

5- Chlordiazepoxide

Answer & Comments

Answer: 3- Thiamine infusion

This patient is exhibiting features of
Wernicke's encephalopathy, which are
nystagmus, ataxia and confusion.

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The daily thiamine requirement for healthy
individuals is between 1 and 2 mg/day but
both alcohol and malnutrition may interfere
with the absorption of thiamine. Thiamine
dependent enzymes such as transketolase
and pyruvate dehydrogenase are essential for
cerebral myelination and thiamine deficiency
in alcoholism leads to Wernicke's
encephalopathy.

Thiamine should also be supplemented fully
in malnourished alcoholics. The
administration of intravenous fluids
containing glucose without adequate
thiamine supplementation in alcoholics could
aggravate the thiamine deficiency leading to
irreversible cerebral lesions.

[ Q: 2403 ] MRCPass - 2012 January

A 30 year old man has had Hepatitis
B testing. The results show:

Anti-HBc Ab positive

Anti-Hbs Ab positive

HBs Ag negative

Which one of the following is likely to be the
correct scenario?

1- Acute Hepatitis B infection

2- Chronic hepatitis B carrier

3- Previous hepatitis B immunisation

4- Previous hepatitis B infection but not a
carrier

5- Not infected with hepatitis B

Answer & Comments

Answer: 4- Previous hepatitis B infection but
not a carrier

A chronic carrier has positive Hep B s Ag and
positive HepB c Ab

A patient with previous immunization has
Hep B s Ag negative and negative Hep B c Ab
and positive Hep B s Antibody, (note that the

core antibody is non specific and not elevated
post immunisation)

A patient with previous Hep B infection who
is not a chronic carrier, has negative Hep B s
Ag and positive Hep B c

Antibody and positive Hep B s Antibody (both
antibodies are positive)

4^ [ Q: 2404 ] MRCPass - 2012 January

* A 56-year-old woman presents with
periods of sweats and tremors which are
relieved by eating. She has gained
approximately 6 kg in weight in the last 2
years. Her BM is 4.5. Blood tests are: Hb 13
g/dl, MCV 78 fl, WCC 7 x 10 9 /l, platelets 200 x
10 9 /l, sodium 135 mmol/I, potassium 4.7
mmol/I, urea 5 mmol/I, creatinine 100
pmol/l, TSH - 3.3 (0.3-4) mU/l, free T4 -20
(10-24) pmol/l.

What is the most appropriate investigation?

1- 72 hour fast

2- CT scan of pancreas

3- MRI of the brain

4- Insulin C-peptide concentration

5- Oral glucose tolerance test

Answer & Comments

Answer: 1- 72 hour fast

This patient has symptoms suggestive of
hypoglycaemia which are relieved by
carbohydrate.

The likely cause is an insulinoma which is an
insulin secreting pancreatic tumour.

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Measurement of C-peptide is useful in
excluding factitious hypoglycaemia from self
injection of insulin. Insulin preparations do
not contain C-peptide.

[ Q: 2405 ] MRCPass - 2012 January

A 61-year-old man is admitted to
the resuscitation room with a GCS score of
13/ 15. He has a past medical history of
hypertension, glaucoma and diabetes. He had
been found unconscious at home. Blood
gases and blood test results taken on
admission show the following:

pH 7.22
pC02- 3.5 kPa
p02 -13.8 kPa
Na+ 140 mmol/l

K+ 4.2 mmol/l

Chloride 110 (95-107) mmol/l
Bicarbonate 10 (20-28) mmol/l
Urea 2.1 mmol/l
Creatinine 79 |imol/l
Glucose 7.1 mmol/l

A day following observation in the
assessment unit, he complained of visual
problems.

Which one of the following diagnoses would
be most consistent with these results?

1- Addisonian crisis

2- Pulmonary embolism

3- Paraquat poisoning

4- Methanol poisoning

which causes retinal toxicity and visual
impairment.

[ Q: 2406 ] MRCPass - 2012 January

A 34-year-old man who has
returned from a holiday in Egypt presents
with diarrhoea. For the past two days he has
been passing frequent bloody diarrhoea
associated with crampy abdominal pain.
Abdominal examination demonstrates diffuse
lower abdominal tenderness but there is no
guarding or rigidity. His temperature is
37.7 °C.

What is the most likely causative organism?

1- Giardiasis

2- Enterotoxigenic Escherichia coli

3- Staphylococcus aureus

4- Shigella

5- Salmonella

Answer & Comments

Answer: 4- Shigella

All are common causes of traveller's
diarrhoea.

However, North Africa and the Middle East (in
particular Egypt) were also commonly
reported regions of travel for Shigella spp
infections.

5- Diabetic ketoacidosis

Answer & Comments

Answer: 4- Methanol poisoning

Methanol poisoning can cause high anion gap
metabolic acidosis and also leads to
formation of formic acid from methanol,

Some of the infectious causes of bloody
diarrhoea are:

Salmonella

Shigella

Campylobacter jejuni
Yersinia enterocolitica

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E. coli

Entamoeba histolytica

[ Q: 2407 ] MRCPass - 2012 January

A 60 year old man has squamous
cell lung cancer and presents with shortness
of breath. He has a history of ischaemic heart
disease. A pleural effusion was tapped and it
showed a transudate.

Which one of the following is a
contraindication tow ards lung resection
surgery?

1- FEV1 of 1.8 L

2- Pleural effusion

3- Hypercalcaemia

4- Superior vena cava obstruction

5- Ischaemic heart disease

Answer & Comments

Answer: 4- Superior vena cava obstruction

SVC obstruction is a contraindication.

With a pleural effusion, there should be
malignant cells demonstrated on cytology to
contraindicate surgery.

Contraindications for surgical resection of
bronchial lung tumour:

FEV1 is less than 1 L

Mediastinal LN >lcm

Staging >IIIB (extrathoracic metastatic
disease)

Nerve involvement is present (rec laryngeal
nerve, vocal cord paralysis)

Malignant pleural effusion is present (positive
cytology)

Horner's syndrome
SVC obstruction

[ Q: 2408 ] MRCPass - 2012 January

A -

# A 33 year old woman presents with
tender, erythematous lesions on both legs
and is offered a mantoux test.

Which one of the following molecules
mediates the action in a mantoux test?

1- Interleukin 2

2- TNF alpha

3- HIF1 alpha

4- Beta interferon

5- CCL1

Answer & Comments

Answer: 2- TNF alpha

The Mantoux Test (MT) is a classical delayed-
type hypersensitivity (DTH) response to the
intradermal injection of tuberculin purified
protein derivative (PPD).

It represents a cutaneous T cell mediated
memory recall immune response.

The presence of IL-1 alpha, IL-1 beta, IL-6,
interferon-gamma (IFN-gamma) and tumour
necrosis factor-alpha (TNF-alpha) are found in
the skin of tuberculin-purified protein
derivative (PPD)-induced reactions.

[ Q: 2409 ] MRCPass - 2012 January

A 70-year-old man with multiple
myeloma presented with sudden onset gross
hematuria to hospital. He had recently been
on chemotherapy and treatment with
predonisolone, cyclophosphamide and
zoledronic acid. He also has a history of
rheumatoid arthritis and hypertension.

Which of the following is the likely cause of
haematuria?

1- Bendroflumethiazide

2- Prednisolone

3- Cyclophosphamide

4- Zoledronic acid

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5- Infliximab

Answer & Comments

Answer: 3- Cyclophosphamide

High dose cyclophosphamide is associated
with haemorrhagic cystitis (severe
haematuria and bladder pains).

Discontinuation of the drug and analgesics
are essential.

[ Q: 2410 ] MRCPass - 2012 January

A 32 year old man presents with
cough and purulent sputum.

He has had several friends with similar
symptoms.

On examinations, there were crepitations in
the left base of the lungs. Chest X ray shows
patchy left lung shadow s. Investigations
show :

Hb 10.5 g/dl

WCC 13 x 10 9 /l

platelets 270 x 10 s /\,

Neutrophil 9 (2 to 7.5) x 10 s /\,

Reticulocyte count 5 (0.5-1.5) %

Which one of the following is the most likely
causative organism?

1- Legionella

2- Staph aureus

3- Streptococcus pyogenes

4- Mycoplasma

5- Pneumocystis

Answer & Comments

Answer: 4- Mycoplasma

There is likely to be cold agglutinins
associated with mycoplasma infection.

Transient acute hemolysis (reticulocytes) may
occur secondary to certain infectious

diseases, such as Mycoplasma pneumoniae
infection and infectious mononucleosis (eg,
EBV) infections.

[ Q: 2411 ] MRCPass - 2012 January

A 37-year-old woman presented
with a 2-year history of progressive dysphagia
to both solids and liquids, as well as a 5 kg
weight loss. She typically complained of
heartburn especially when lying down and
after food. A chest X ray showed dilatation of
the oesophagus with a fluid level.

What is the most likely diagnosis?

1- Oesophageal diverticulum

2- Pancreatic malignancy

3- Achalasia

4- Gastroduodenal ulcer

5- Zollinger Ellison syndrome

Answer & Comments

Answer: 3- Achalasia

Achalasia is characterized by difficulty
swallowing, regurgitation, and sometimes
chest pain.

The lower esophageal sphincter fails to relax,
leading to dilatation of the oesophagus. On a
barium swallow , this leads to a bird's beak
appearance.

[ Q: 2412 ] MRCPass - 2012 January

An 18-year-old man presented
casualty complaining of difficulty breathing.
He had brought hospital by ambulance,
having collapsed shortly after being stung on
hand by a bee. On examination, his blood
pressure was 80/40 mmHg, facial sw elling
and pharyngeal oedema was noted.

Which one of following investigations likely
confirm anaphylaxis?

1- Haemolytic complement (CH50) level

2- Plasma tryptase activity

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3- Complement C3 level

4- Total IgE level

5- Eosinophil count

Answer & Comments

Answer: 2- Plasma tryptase activity

The reaction involves preferential production
of IgE, in response certain antigens, which in
turn initiates a sequence of events leading to
mast cell activation.

According to the Resuscitation council
guidelines, the specific test to help confirm a
diagnosis of an anaphylactic reaction is
measurement of mast cell tryptase.

Tryptase is the major protein component of
mast cell secretory granules. In anaphylaxis,
mast cell degranulation leads to markedly
increased blood tryptase concentrations
(Figure 4). Tryptase levels are useful in the
follow-up of suspected anaphylactic
reactions, not in the initial recognition and
treatment: measuring tryptase levels must
not delay initial resuscitation. Tryptase
concentrations in the blood may not increase
significantly until 30 minutes or more after
the onset of symptoms, and peak 1-2 hours
after onset.

The half-life of tryptase is short
(approximately 2 hours), and concentrations
may be back to normal within 6-8 hours, so
timing of any blood samples is very
important.

Physical examination revealed mild wheezes
on auscultation. The remainder of his physical
examination was unremarkable. A chest x ray
showed hyperinflated lungs with large bullae.

Pulmonary function testing at presentation
demonstrated :

forced expiratory volume in one second
(FEV1) was 2.10 litres (61% of the predicted
value)

forced vital capacity (FVC) was 3.60 litres
(81% of the predicted value)

the FEV1:FVC ratio was 0.59

total lung capacity (TLC) was 6.40 litres (93%
of the predicted value)

residual lung volume (RV) was 2.91 litres
(123% of the predicted value)

There was minimal response to an inhaled
bronchodilator.

What is the likely diagnosis?

1- Asthma

2- Bronchiectasis

3- Emphysema

4- Silicosis

5- Usual interstitial pneumonitis

Answer & Comments

Answer: 3- Emphysema

There is evidence of obstructive picture
(reduced FEV1/FVC ratio) and hyperinflation
on lung function tests.

http://www.resus.org.uk/pages/reaction.pdf

[ Q: 2413 ] MRCPass - 2012 January

A 50-year-old man presented with
an initial complaint of dyspnea on exertion
that had developed five years prior and had
progressed to shortness of breath while
walking up one flight of stairs. He smokes 20
cigarettes and drinks 2 units of alcohol per
day.

This is in keeping with smoking related
emphysema of the lungs.

[ Q: 2414 ] MRCPass - 2012 January

A 69-year-old man was admitted for
evaluation of a new blistering rash. He has a
history of hypertension and epilepsy. He
normally takes bendroflumethiazide and
phenytoin. On the day of admission,
complained of soreness in his mouth and that

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his hands were sore. His conjunctivae were
mildly erythematous, and both upper eyelids
had superficial erosions. His oral cavity
revealed multiple shallow , 3 mm erosions
with hemorrhagic crusting extending from the
lips to the soft palate. His right chest revealed
a 3 cm full-thickness erosion. Both palms had
full-thickness, necrotic erosions with
surrounding, partially blanching erythema of
the digits. The soles of both feet were
erythematous.

What is the likely diagnosis?

1- Toxic epidermal necrolysis

2- Erythrodermic psoriasis

3- Eczema herpeticum

4- Bullous pemphigoid

5- Erythema multiforme

Answer & Comments

Answer: 1- Toxic epidermal necrolysis

Toxic epidermal necrolysis (TEN) is a
potentially life-threatening dermatologic
disorder characterized by widespread
erythema, necrosis, and bullous detachment
of the epidermis and mucous membranes,
resulting in exfoliation and possible sepsis
and/or death (see the image below).

Mucous membrane involvement can result in
gastrointestinal hemorrhage, respiratory
failure, ocular abnormalities, and

genitourinary complications.

TEN is most commonly drug induced.
However, the disorder has other potential
etiologies, including infection, malignancy,
and vaccinations. Antibiotics such as

macrolides and sulphonamides are
associated. Anticonvulsants such as
phenytoin and carbamazepine are also
associated. TEN in patients taking

anticonvulsants has most often been
reported within 2 months of starting the
drug.

4^ [ Q: 2415 ] MRCPass - 2012 January

# A 21-year-old man presents with
lethargy, pyrexia and headaches. These
symptoms have been present for the past 8
days. He had not been unwell before and
there is no recent history of travel. Clinical
examination reveals a temperature of 37.9°C,
marked cervical lymphadenopathy and mild
hepatomegaly. Throat examination reveals
two small erythematous areas. A full blood
count result shows:

Hb 13.1 g/dl

Platelets 225 x 10 9 /l

WCC 17.1xl0 9 /l

Neut 5.2 xll0 9 l

Lymp 11.2 x 10 9 /l

Blood Film Atypical lymphocytes seen
What is the most likely diagnosis?

1- Acute lymphoblastic leukaemia

2- Hashimoto's thyroiditis

3- Infectious mononucleosis

4- HIV seroconversion

5- Septicaemia secondary to streptococcal
throat infection

Answer & Comments

Answer: 3- Infectious mononucleosis

Atypical lymphocytes are commonly
associated with EBV, CMV and toxoplasma
infection.

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Reactive lymphocytes are lymphocytes that
become large as a result of antigen
stimulation.

[ Q: 2417 ] MRCPass - 2012 January

In a dehydrated patient,
compensatory water retention takes place.
Despite this, in which part of the nephron
does water absorption not take place?

1- Proximal convoluted tubule

2- Descending limb Loop of Henle

3- Ascending limb Loop of Henle

4- Distal convoluted tubule

5- Collecting duct

[ Q: 2416 ] MRCPass - 2012 January

A 35 year old man has has been
investigated for liver cirrhosis and been
diagnosed as having Wilson's disease.

His wife has had no symptoms but knows that
there is a single copy of the gene is present in
1 in 100 people. He asks what is the chance
that his children might have Wilson's disease.

What is the risk of each child having the
disease?

1- None

2- 1 in 50

3- 1 in 100

4- 1 in 200

Answer & Comments

Answer: 3- Ascending limb Loop of Henle

Unlike the descending limb, the ascending
limb of Henle's loop is impermeable to water,
a critical feature of the countercurrent
exchange mechanism employed by the loop.

The ascending limb actively pumps sodium
out of the filtrate, generating the hypertonic
interstitium that drives countercurrent
exchange. Though the collecting duct is
normally impermeable to water, it becomes
permeable under the actions of antidiuretic
hormone (ADH). As much as three-fourths of
the water from urine can be reabsorbed as it
leaves the collecting duct by osmosis.

5- 1 in 1000

Answer & Comments

Answer: 4-1 in 200

Wilson's disease is inherited in an autosomal
recessive pattern.

A single abnormal copy of the gene is present
in 1 in 100 people. In this case since the man
already has both copies of the gene and the
wife has a 1 in 100 chance of being a carrier,
thus each child will has half the risk because if
the wife was a carrier she has one normal and
one gene for Wilson's disease. Half of 1 in 100
chance is 1 in 200.

[ Q: 2418 ] MRCPass - 2012 January

A 20 year old female is referred to
the hospital. Her family are concerned about
her because she has been very agitated in the
last 2 days. She has no past medical history of
note. On examination, she looks restless and
has significantly dilated pupils.

What is the likely cause of mydriasis?

1- Alcohol

2- Barbiturates

3- Diazepam

4- Cocaine

5- Opiates

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Answer & Comments

Answer: 4- Cocaine

This patient is likely to have taken a stimulant
which has made her restless and agitated.

The most common stimulants taken as
recreational drugs are amphetamines and
cocaine. They also often cause dilated pupils
(mydriasis).

[ Q: 2419 ] MRCPass - 2012 January

A 63-year-old man is examined in
the cardiology clinic. During cardiac
examination it is noted that the pulmonary
component of the second heart sound occurs
before the aortic component.

Which one of the following is associated with
this finding?

1- Pulmonary stenosis

2- Left bundle branch block

3- Right bundle branch block

4- Atrial septal defect

5- Deep inspiration

Answer & Comments

Answer: 2- Left bundle branch block

This patient has reversed splitting of the
second heart sound.

LBBB and left heart strain in HCM and aortic
stenosis can cause reversal of A2P2 second
heart sounds. Also, in type B wolf parkinson
white syndrome, early activation of the right
ventricle through an accessory pathway can
cause P2 to close prematurely. Patent ductus
arteriosus is another cause.

[ Q: 2420 ] MRCPass - 2012 January

A 40-year-old woman has presented
with an erythematous annular patch with
central clearing on her left foot.

She likes walking and has been hiking on hills
recently. The patient mentioned that the rash
has gotten progressively larger and spreading
up the leg over the last 3 weeks and she has
had a recent onset of intermittent joint pains.
On examination, there is a large area of
erythema with a central clearing over the left
leg.

What is the likely diagnosis?

1- Staphylococcal infection

2- Lyme disease

3- Pastereulla infection

4- Necrotising fasciitis

5- Gonorrhoea

Answer & Comments

Answer: 2- Lyme disease

Lyme Disease (LD) is a multisystem disease
affecting the nervous system, skin, joints, and
heart.

Erythema migrans (EM), the characteristic
dermatologic lesion of LD, is an expanding red
papule or macule with central clearing, often
found in the axilla, midriff, or popliteal areas.

B. burgdorferi is transmitted by the tick
Ixodes, a hard bodied tick found in wooded
areas. Lyme disease occurs in 3 stages: early
localized, early disseminated, and late. If left
untreated, each stage progresses to the next.
Early localized disease manifests within 3-30
days presenting with erythema migrans (EM),
myalgia, fatigue, headache, fever,
lymphadenopathy, and arthralgia. Early
disseminated disease occurs 30 to 120 days
post-infection and is characterized by EM
(single or multiple), fatigue,
lymphadenopathy, conjunctivitis, neck pain,
cardiac abnormalities, radiculoneuritis,
arthritis, and CNS manifestations. Late
disease manifests from 4 months to 1 year,
presenting with fatigue, chronic arthritis, CNS
manifestations, and encephalopathy.

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First-line treatment for early disease is
doxycycline (100 mg PO twice a day for 14 to
21 days) or amoxicillin (500 mg PO three
times a day for 14 to 21 days).

[ Q: 2421 ] MRCPass - 2012 January

With which one of the following
carcinomas, is the RET oncogene associated ?

1- Anaplastic thyroid carcinoma

2- Follicular thyroid carcinoma

3- Papillary thyroid carcinoma

4- Medullary thyroid carcinoma

5- Parathyroid carcinoma

Answer & Comments

Answer: 4- Medullary thyroid carcinoma

The RET proto-oncogene encodes a receptor
tyrosine kinase.

sodium 135 mmol/l
potassium 4.5 mmol/l
urea 5 mmol/l
creatinine 90 |imol/l
IgA 0.2(0.5-4.0) g/l
IgG 0.35 (5.0-13.0) g/l
IgM 0.2 (0.3-2.2) g/l
What is the diagnosis?

1- Cystic fibrosis

2- Kartagener's syndrome

3- HIV infection

4- Common variable immunodeficiency

5- Tuberculosis infection

Answer & Comments

Answer: 4- Common variable

immunodeficiency

RET dysfunction mutations are associated
with the development of medullar thyroid
carcinoma and multiple endocrine neoplasias
type II and III (formerly types 2A and 2B) and
Hirschsprung's disease.

[ Q: 2422 ] MRCPass - 2012 January

n -

* A 39-year-old male was admitted
hospital with a two week history of cough and
diarrhoea. He has a history of recurrent
respiratory infections, otitis media, and
sinusitis starting from adolescence. He also
had a severe episode of meningoencephalitis
and inguinal abscesses. A chest X ray showed
patchy consolidation and he went to have a
CT scan of the chest which showed bilateral
changes consistent with bronchiectasis.

Blood test results are:

Hb 12.5 g/dl

MCV 75 fl

WCC 6 x 10 9 /l

platelets 180 x 10 9 /l

Common variable immunodeficiency (CVID) is
a group of approximately 150 primary
immunodeficiencies which have a common
set of features (including

hypogammaglobulinemia) but which have
different underlying causes.

Recurring infections involving the ears, eyes,
sinuses, nose, bronchi, lungs, skin, Gl tract,
joints, bones, CNS, parotid glands are a
feature.

Another feature is hypogammaglobulinaemia
with low levels of IgA, IgG and IgM.

[ Q: 2423 ] MRCPass - 2012 January

A study was conducted to
investigate the effect of a new antiplatelet
drug. It compared the number of survivors of
myocardial infarction with those who died
after a 2 year period of being on the drug
versus a placebo.

Which one of the following tests is best used
to compare the effects of the drug on
survival?

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1- Mann Whitney test

2- Logistic regression analysis

3- Spearmann's correlation

4- Chi square test

5- Kaplan Meier curve

Answer & Comments

Answer: 4- Chi square test

The chi square test is most appropriate here
for comparing drug treatment and placebo
groups and survival.

Survived Not Survived

With Drug A B

Without Drug C D

[ Q: 2424 ] MRCPass - 2012 January

A 75 year man was found collapsed
at home and brought to the emergency
department.

He has a past history of coronary artery
bypass grafting, stroke and diabetes. He was
unable to give a history. On examination, he
was covered with multiple bruises. A dipstick
urine analysis shows Blood ++++, protein +,
glucose -ve.

Some of his investigation results are listed
below:

sodium 135 mmol/l
potassium 4.5 mmol/l
urea 5 mmol/l
creatinine 300 pmol/l
AST 320 (1-31) U/l

What likely cause of the raised serum
creatinine concentration?

1- Urinary tract infection

2- Glomerulonephritis

3- Nephrotic syndrome

4- Nephritic syndrome

5- Myoglobinuria

Answer & Comments

Answer: 5- Myoglobinuria

The elevated serum creatinine likely to be
due to rhabdomyolsis.

The positive urinalysis is caused by myoglobin
a muscle protein released during muscle
damage. High amounts of myoglobin
damages the renal tubules which then leads
to acute kidney injury.

t\ \

[ Q: 2425 ] MRCPass - 2012 January

A 29 year old man presented to the

emergency deparment with a severe
exacerbation of asthma. He responded poorly
to aggressive therapy with systemic
corticosteroids (prednisolone 40 mg) 100%
oxygen and continuous inhaled beta
agonist/anticholinergic therapy. He had a
history of poorly controlled asthma, for which
he had been hospitalized six months ago. He
is drow sy, confused and lethargic. His PC02 8
kPa and his Sa0 2 (oxygen saturation) has
fallen to 85%, despite the oxygen therapy.

Which one of the following is an indication for
intubation?

1- Not completing sentences

2- Using accessory muscles

3- Elevated C02 levels

4- Wheezing in the chest

5- Pneumothorax

Answer & Comments

Answer: 3- Elevated C02 levels

Asthmatic patients who respond poorly to
aggressive, inhaled bronchodilator therapy
and intravenous steroids should be carefully
monitored for progressive type II respiratory
failure.

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A sign of type II respiratory failure in asthma
patients who are young and otherwise
healthy is a normal or increasing partial
pressure of carbon dioxide (PC02).

It is an indication for intubation.

[ Q: 2426 ] MRCPass - 2012 January

A 68-year-old woman presents with
a vesicular rash in the trigeminal distribution
on the left side of her face. This was
diagnosed as herpes zoster infection and she
recovered. Several weeks following the
episode, she describes having severe pains
several episodes a day which, each lasting for
several minutes up to 2 hours.

The drug did not respond to nonsteroidal anti
inflammatory drugs and paracetamol.

What drug should be commenced?

1- Oramorph

2- Sodium valproate

3- Carbamazepine

4- Phenytoin

5- Tramadol

Answer & Comments

Answer: 3- Carbamazepine

The clinical history is typical for post herpetic
neuralgia.

Neuropathic agents such as carbamazepine
and gabapentin are recommended for its
treatment.

[ Q: 2427 ] MRCPass - 2012 January

A 66-year-old woman comes to the
clinic for a review of symptoms. Over the past
three months she has been complaining of
fatigue and a full blood count was requested:

Hb 8.4 g/dl
MCV 69 fl
Pit 362 x 10 9 /l

WBC 5.0 xl07l

Blood film Hypochromic, microcytic picture

An upper Gl endoscopy was reported as
normal.

What is the most appropriate next
investigation?

1- Barium swallow

2- Faecal occult blood

3- Colonoscopy

4- Schilling test

5- Reticulocyte count

Answer & Comments

Answer: 3- Colonoscopy

There is evidence of iron deficiency anaemia.

Although the OGD is normal, a colonoscopy
should be considered to exclude sources of
bleeding e.g. angiodysplasia or colorectal
cancer

[ Q: 2428 ] MRCPass - 2012 January

A 40 year old man has a tetanus
injection at the GP surgery. 3 hours following
this he presents unwell to A&E.

His blood pressure was 75/50 mmHg, he has a
pulse rate of 115 and 02 saturation of 98% on
air. There was erythema around the site of
the tetanus injection on his arm.

Which type of hypersensitive reaction is this?

1- Type 1

2- Type 2

3- Type 3

4- Type 4

5- Type 5

Answer & Comments

Answer: 1- Type 1

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This is an allergic or anaphylactic reaction due
to the hypotension and erythema.

Classifications for hypersensitivity are:

Type 1: allergy - asthma, anaphylaxis

Type 2: cytotoxic - autoimmune haemolytic
anaemia, goodpasture's syndrome

Type 3: immune complex - SLE

Type 4: delayed hypersensitivity - Mantoux
test, multiple sclerosis

Type 5: autoimmune - Grave's disease,
myasthenia gravis

[ Q: 2429 ] MRCPass - 2012 January

A 30 year old woman has just
returned from south east asia and was bitten
by mosquitoes. She has a fever and a malarial
film is positive. She was given a course of
chloroquine and primaquine.

Why is primaquine used?

1- To reduce multiplication of parasites in
blood stream

2- To eradicate hepatic forms of parasite

3- To reduce reaction to chloroquine

4- To prevent repeat infection

5- To treat falciparum malaria

Answer & Comments

Answer: 2- To eradicate hepatic forms of
parasite

Primaquine (or primaquine phosphate) is a
medication used to treat the P. vivax or P.
ovale malaria. Once the parasite has been
eliminated from the bloodstream, the
remaining hypnozoites must be removed
from the liver and this is done by
administering a 14 day course of primaquine.
This process is called a radical cure.

[ Q: 2430 ] MRCPass - 2012 January

A 75 year old patient presents with
dizziness and an episode of collapse. The ECG
on admission shows complete heart block.
The patient has a single lead pacemaker
inserted.

What anatomical site should the pacemaker
wire tip be inserted?

1- Right atrium

2- Right ventricular apex

3- Left ventricular apex

4- Coronary sinus

5- Atrioventricular node

Answer & Comments

Answer: 2- Right ventricular apex

The most basic form of a pacemaker is a VVI
pacemaker where the tip of the pacemaker
lead is inserted through the superior vena
cava then through the tricuspid valve and into
the right ventricular apex.

This is also the case where a temporary wire
which needs to be inserted such that the tip
sits in the right ventricular apex.

[ Q: 2431 ] MRCPass - 2012 January

A 70 year old lady has longstanding
lethargy. On physical examination she had a
plethoric face & conjunctival injection.
Investigations revealed:

hemoglobin 18.5 g/dl (12-16 g/dl)

red cell count 8.1 M/?l (3.5 to 6 M/?l)

Hct. 58.% (37 to 52%)

MCV 65.7fL (67 to 96 fL)

MCH 19.6 pg (27 to 32 pg)

Platelet 720 (150-400) x 10 9 /l WBC 13.1 x

10 9 /l

ESR 2 mm/hour

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Blood film showed erythrocytosis,
thrombocytosis and leucocytosis.

With the diagnosis in mindl which drug should
be commenced?

1- Clopidogrel

2- Bortezomib

3- Infliximab

4- Cyclosporin

5- Hydroxycarbamide

Answer & Comments

Answer: 5- Hydroxycarbamide

weight loss, back pain and stiffness. Clinical
examination showed very restricted neck
movement and chest expansion with no
lumbar spinal movement. X rays of the
patient's spine were performed.

What feature would be expected on the x rays
in ankylosing spondylitis?

1- Osteosclerosis

2- Syndesmophyte

3- Lytic lesions

4- Osteophyte

5- Wedge shaped lesions

The diagnosis in this case is polycythaemia
rubra vera.

Janus kinase 2 (commonly called JAK2) is a
human protein that has been implicated in
signaling by members of the type II cytokine
receptor family. These mutations have been
associated with polycythemia vera, essential
thrombocythemia, and other

myeloproliferative disorders.

Low dose aspirin is indicated if there are no
contraindications.

Short, intermittent courses of cytoreductive
therapy be administered to patients who
have had thrombotic episodes or in whom
platelet count continues to rise despite
repeated phlebotomy.

Interferon is first-line cytoreductive therapy
in the younger patients (< 40 years old).

Hydroxycarbamide is used as first line
cytoreductive therapy in patients 40-75 years
old.

Anagrelide is a second line cytoreductive
therapy in these age groups.

[ Q: 2432 ] MRCPass - 2012 January

A 44-year-old male developed neck
pain which had worsened over several years.
He presented to a rheumatologist with

Answer & Comments

Answer: 2- Syndesmophyte

Typical X ray changes of ankylosing
spondylitis are the visible formation of
syndesmophytes (bony growth originating
inside a ligament) and abnormal bone
outgrow ths similar to osteophytes affecting
the spine.

These changes lead to an appearance of
'bamboo spine'.

Syndesmophyte

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[ Q: 2433 ] MRCPass - 2012 January

An 80 year old woman is brought in
after being found collapsed. She had not been
seen by her neighbor overnight and may have
been on the floor for many hours. Her
temperature on admission was 33 C.

Which feature may be a sign of hypothermia
on the ECG?

1- Short PR interval

2- Right axis deviation

3- Tented T waves

4- Reversed Tick sign

5- Prolonged QT

Lithium level 6.5 mmol/l (0.4 to 1.0) mmol/L

Na+ 136 mmol/l

K+ 4.6 mmol/l

Urea 6.1 mmol/l

Creatinine 92 pmol/l

Bicarbonate 25 mmol/l

What is the most appropriate management?

1- Intravenous magnesium

2- Intravenous bicarbonate

3- Intravenous normal saline

4- Arrange for haemodialysis

5- Arrange for plasma exchange

Answer & Comments

Answer: 5- Prolonged QT

The following are characteristic of the ECG
changes in the hypothermic patient:

■ atrial fibrillation

J-waves - which are pathognomonic
of hypothermia
PR elongation

■ QRS widening
QT elongation

4+ [ Q: 2434 ] MRCPass - 2012 January

# A 41-year-old man with a history of
bipolar disorder is admitted with acute
confusion.

Whilst being transferred to hospital he had
generalised seizure which terminated
spontaneously after around 30 seconds. On
arrival in the Emergency Department his GCS
is 142/15 and he is noted to have a
generalised tremor. A diagnosis of lithium
toxicity is suspected. Intravenous access is
obtained, bloods are taken and a saline
infusion is started. Blood results reveal the
following:

Answer & Comments

Answer: 4- Arrange for haemodialysis

The high lithium level and reduced GCS are an
indication for haemodialysis in this patient.

Haemodialysis should be considered in any
cases of lithium level > 4 mmol/l.

[ Q: 2435 ] MRCPass - 2012 January

£ -

A 35-year old woman complained of

visual symptoms and presents for
assessment. She complained of pain, reduced
visual acuity, visual disturbance and blurred
vision in the left eye. Her left visual acuity was
6/20. Light reflex in the left eye was reduced.
The relative afferent pupillary defect (RAPD)
was positive in the left eye where a central
scotoma was present. Fundoscopy revealed a
pale disc on the left retina.

What is the clinical diagnosis?

1- Retinitis pigmentosa

2- 3rd nerve palsy

3- Optic neuritis

4- Acute glaucoma

5- Retinal artery thrombosis

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Answer & Comments

Answer: 3- Optic neuritis

The afferent pupillary defect suggest that the
left eye optic nerve is affected, and a central
scotoma suggests optic neuritis.

Common clinical features of optic neuritis are
variable loss of central vision which usually
recovers within 2-6 weeks and dull aching
pain in the region of the eye. The visual field
defect is most commonly a central scotoma.

There may be loss of colour vision and
relative afferent pupillary defect. Multiple
sclerosis is the most common cause of optic
neuritis accounting for 50% of cases. Other
causes include toxic amblyopia,
toxoplasmosis, diabetes, syphilis, herpes
zoster and infectious mononucleosis.

[ Q: 2436 ] MRCPass - 2012 January

A 62-year-old woman is investigated
for weight loss, fatigue and anaemia. She has
no past medical history of note. Clinical
examination reveals splenomegaly associated
with pallor. A full blood count is reported as
follows:

Hb 9.8 g/dl

Platelets 380 x 10 9 /l

WCC 120 x 10 9 /l

Blood film. Demonstrates left shift with
predominating myelocytes. Low percentage
of blast cells

What is the most appropriate treatment?

1- Chlorambucil

2- Imatinib

3- Thalidomide

4- Rituximab

5- Hydroxycarbamide

Answer & Comments

Answer: 2- Imatinib

The diagnosis here is chronic myeloid
leukaemia, which accounts for 20% of all
leukaemias.

It occurs mainly in middle aged and elderly
people and is characterised by marked
leucocytosis, a left shifted myeloid series and
in 95% of patients, the Philadelphia
chromosome.

[ Q: 2437 ] MRCPass - 2012 January

/ ---—

# A 71-year-old woman presented to

the emergency room with an acute history of

progressive exertional chest pain. The pain

was sharp and was associated with shortness

of breath. Physical activity made it worse and

improvement was noted with sublingual

nitroglycerin. On arrival to the department

her blood pressure was 105/62 mmHg, pulse

was 98 beats per minute. Cardiac

examination revealed a regular heart with no

murmur, rubs or gallop. The ECG showed

sinus rhythm with low voltage, left axis

deviation with ST, lateral T wave

abnormalities and elevated cardiac enzymes

Her Troponin T levels peaked at 5ng/ml (<

O.lOng/ml). The following day, her chest

pains subsided but she developed fevers,

myalgia and a mottled discoloration of both

her legs.

What other finding is likely?

1- Anaemia

2- Polycythaemia

3- Thrombocytopenia

4- Eosinophilia

5- Haemolysis

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Answer & Comments

Answer: 4- Eosinophilia

This patient had a myocardial infarction and
has developed cholesterol emboli probably
due to severe atherosclerosis of the aorta.

[ Q: 2438 ] MRCPass - 2012 January

A 70-year-old man presented to the
hospital with sudden onset of double vision
and a 1 month history of chronic headache.
On examination, he had a left sided 3rd nerve
palsy and a dilated pupil. His blood tests show
no abnormality. Magnetic resonance imaging
was organised.

on the oculomotor nerve or ischemia.

^ [ Q: 2439 ] MRCPass - 2012 January

fit -

# A 46 year old lady presented to her
physician with complaints of weakness and
headaches for several months.

At presentation, she was found to have
severe hypertension with blood pressure
180/110 mmHg. Her blood test results are:

sodium 149 mmol/l

potassium 2.9 mmol/l

urea 7 mmol/l

creatinine 100 |imol/l

What test should be done next?

1- Thyroid function test

2- Renin:aldosterone ratio

3- Abdominal MRI

4- Intrapetrosal venous sampling

5- 24 hour urine for catecholamines

Answer & Comments

Answer: 2- Renin:aldosterone ratio

What is this likely to show?

1- Encephalitis

The clinical diagnosis for this case is Conn's
syndrome.

2- Meningioma in the frontal lobe

3- Brainstem glioma

4- Posterior communicating artery aneurysm

5- Occipital territory infarct

Answer & Comments

Answer: 4- Posterior communicating artery
aneurysm

Compression of the oculomotor nerve
resulting in third nerve palsy is most
commonly caused by posterior
communicating artery aneurysm.

In these cases, third nerve palsy typically
develops in response to direct pressure

Conn syndrome is characterized by increased
aldosterone secretion from the adrenal
glands, suppressed plasma renin activity
(PRA), hypertension, and hypokalemia as
seen in the above case. Routine laboratory
studies can show hypernatremia,
hypokalemia, and metabolic alkalosis
resulting from the action of aldosterone on
the distal tubule of the kidney.
Renin:aldosterone ratio is a good screening
test for the patient. If this suggested Conn's
syndrome, then an abdominal MRI to identify
an adrenal lesion should be done.

[ Q: 2440 ] MRCPass - 2012 January
A 30-year-old woman with a history

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of migraine for 2 years presented to the
emergency ward with complaints of visual
disturbances. She had noted an increase in
frequency of headache over the past few
months. The patient's past medical history
was unremarkable. She was taking NSAIDs for
headaches. She was a non-smoker.

On physical examination, the patient's blood
pressure level was 120/70 mm Hg. On
neurologiccal examination, there was no focal
limb weakness and mental test function was
normal. She had a bilateral homonymous
superior quadrantanopia.

What is the most likely cause?

1- Craniopharyngioma

2- Pituitary macroadenoma

3- Sagittal meningioma

4- Glioma

5- Subdural haematoma

Answer & Comments

Answer: 2- Pituitary macroadenoma

Pituitary tumours often enlarge upwards,
hence compressing the optic chiasm.

the visual field defect will first appear as
bitemporal superior quadrantanopia and
eventually leading to bitemporal hemianopia.

If originating superior to the optic chiasm,
more commonly in a craniopharyngioma of
the pituitary stalk, the visual field defect will
first appear as bitemporal inferior
quadrantanopia.

[ Q: 2441 ] MRCPass - 2012 January

A 53-year-old woman presented to
the emergency department with complaints
of intermittent fatigue, nausea and itching for
several months. She complains of having a
constant dry mouth. She had a past medical
history of hypothyroidism. She had a 20 pack-
year smoking history and alcohol intake
consisted of a maximum of 4 units a day. On

examination, she was jaundiced and had
palpable hepatomegaly. She was noted to
have excoriation marks on the skin and
xerostomia.

Blood results are: Hb 12.5 g/dl, WCC 7 x 10 9 /l,
platelets 235 x 10 9 /l, sodium 136 mmol/l,
potassium 4.5 mmol/l, urea 6 mmol/l,
creatinine 110 pmol/l, ALT 90 (5-35) U/l, AST
68 (1-31) U/l, ALP 650 (20-120) U/l, GGT 90
(4-35) U/l, Bilirubin 125 (1-22) |imol/l,
Albumin 38 (37-49) g/l.

What test should be sent to help confirm the
diagnosis?

1- Antinuclear antibody

2- Anti parietal cell antibody

3- Anti gliadin antibody

4- Anti smooth muscle antibody

5- Anti mitochondrial antibody

Answer & Comments

Answer: 5- Anti mitochondrial antibody

The patient has a cholestatic picture (high
alkaline phosphatase and bilirubin) in the
liver function tests, and hence out of all the
options, primary biliary cirrhosis is most
likely.

Antimitochondrial antibody is often positive.
Fatigue is the first reported symptom,
pruritus is also a common symptom.
Examination findings usually include
hepatomegaly and xanthelasmata.

[ Q: 2442 ] MRCPass - 2012 January

A 26-year-old man presented to the
hospital with sw elling of his hands and feet,
progressive dyspnoea and weight gain in
excess of 10 kg in the week prior to
admission. On examination he had a blood
pressure of 180/80 mmHg, heart rate of 90
and respiratory rate of 16/min. There were
no skin lesions or lymphadenopathy, and all
pulses were palpable. There was 3+ pitting

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pedal oedema to the upper thighs and
periorbital oedema. Urine dipstick showed
proteinuria 4+.

immunosuppressants is given. The choice of
immunosuppressants includes

cyclophosphamide and chlorambucil.

A percutaneous renal biopsy showed many
glomeruli with normal appearance. Electron
microscopy showed areas of visceral
epithelial podocyte effacement and fusion
without evidence of immune deposits, and
minimal change glomerulonephritis is
diagnosed.

What treatment is most likely to reduce
proteinuria?

1- Cyclophosphamide

2- Aciclovir

3- Lisinopril

4- Prednisolone

5- Intravenous immunoglobulin

Answer & Comments

Answer: 4- Prednisolone

Angiotensin converting enzyme inhibitors and
angiotensin II receptor blockers, alone or in
combination should be used with a goal of
reducing the proteinuria. Blood pressure and
renal function should be monitored closely in
patients on angiotensin converting enzyme
inhibitors and angiotensin II receptor
blockers.

[ Q: 2443 ] MRCPass - 2012 January

A 63 year old woman has recently
had lethargy and arthralgia. She was
diagnosed as having influenza infection, as
there was an outbreak in the area recently.
She presents 1 week later with a cough and
breathlessness. On examination, she had
bilateral crackles audible on examination. CXR
confirms bilateral consolidation and
infiltrates.

The patient has minimal change disease
(MCD).

It is postulated that MCD is a disorder of T
cells, which release a cytokine that injures the
glomerular epithelial foot processes.
Oedema, hypertension and proteinuria are
common presentations. The renal biopsy
often shows normal appearances but on
electron microscopy, there is diffuse loss of
visceral epithelial cells (podocyte) foot
processes.

Corticosteroids are the treatment of choice,
leading to complete remission of proteinuria
in most cases.

Approximately 90% of children respond
within 2 weeks to prednisone at a dose of 60
mg/msq/d. Adults respond more slow ly than
children. A response in up to 80-90% has
been recorded in adolescents and adults.
However, the time to remission is up to 16
weeks. If patients are steroid-resistant or they
relapse frequently, a trial of

Which one of the following is most likely as a
cause?

1- Legionella

2- Mycoplasma

3- Streptococcus pneumoniae

4- Klebsiella

5- Staphylococcus aureus

Answer & Comments

Answer: 5- Staphylococcus aureus

Normal incidence of staph aureus pneumonia
is 2%, However this is significantly increased
in iv drug users and influenzae virus
infections.

Post influenzae staph aureus pneumonia is
characterised by rapid clinical deterioration
with septicaemia.

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[ Q: 2444 ] MRCPass - 2012 January

A 25 year old man was admitted to
hospital with frequent bloody diarrhea (10-15
bow el motions/day), abdominal pain, and
fever for a period of 3 months. There is no
history of recent travel and the patient did
not respond to courses of antibiotics given by
the GP. On admission, physical examination
showed a temperature of 37.5°C; the
abdomen was soft, but there was moderate
tenderness in the lower abdomen.

A blood film showed hypochromia, slight
microcytosis and anisocytosis, a few target
cells, and basophilic stippling.

What is the diagnosis?

1- Sideroblastic anaemia

2- Alpha thalassemia trait

3- Beta thalassemia trait

4- Acute intermittent porphyria

5- Lead poisoning

A colonoscopy was performed. This showed
large areas of continuous severe
inflammatory changes of congestion, oedema
and irregular abscesses around the sigmoid
colon with diverticulae seen.

What is the diagnosis?

1- Diverticulitis

2- Crohn's disease

3- Ulcerative colitis

4- Inflammatory colitis

5- Ischaemic colitis

Answer & Comments

Answer: 3- Ulcerative colitis

The history of bloody diarrhea is typical of
ulcerative colitis.

Answer & Comments

Answer: 3- Beta thalassemia trait

The blood film shows an iron deficiency
picture, target cells and basophilic stippling.

Additionally the patient is asymptomatic and
there are elevated HBA2 levels, hence it fits a
thalassemia trait. Below are descriptions of
some of the options.

(3 thalassemia trait (minor): This trait is
characterized by mild anemia and low RBC
indices. This condition is typically caused by
the deletion of 2 ? (a) genes on one
chromosome 16 (aa/oo) or one from each
chromosome (ao/ao).

This condition is encountered mainly in
Southeast Asia, the Indian subcontinent.

The biopsy specimen showing severe areas of
inflammation are typical of colitis. In this
case, although there are diverticulae,
diverticulitis should not cause such large
areas of inflammatory changes.

[ Q: 2445 ] MRCPass - 2012 January

A 44-year-old South Asian man had
a routine blood test with his GP. He has no
symptoms. These results were found:

Hb 10.5 g/dl, MCV 75 fl, WCC 7 x 10 9 /l,
platelets 220 x 10 9 /l, HbA2 5% (<3.5%)

a thalassemia trait (minor): Patients have mild
anemia, abnormal RBC indices, and abnormal
Hb electrophoresis results with elevated
levels of Hb A2, Hb F, or both. Peripheral
blood film examination usually reveals
marked hypochromia and microcytosis
(without the anisocytosis usually encountered
in iron deficiency anemia), target cells, and
faint basophilic stippling. The production of a
chains from the abnormal allele varies from
complete absence to variable degrees of
deficiency.

[ Q: 2446 ] MRCPass - 2012 January
A 21-year-old lady with polycystic

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ovary syndrome was prescribed Metformin.
How does Metformin acts in this situation?

1- Increasing oestradiol levels

2- Increasing luteinising hormone levels

3- Increasing gluconeogenesis

4- Increasing insulin levels

5- Increasing peripheral glucose utilisation

Thoracic outlet syndrome is a syndrome
involving compression at the superior
thoracic outlet involving compression of a
neurovascular bundle. It can affect the
brachial plexus and/or the subclavian artery.

The compression may be positional (caused
by movement of the clavicle and shoulder
girdle on arm movement), a first rib fixation
and a cervical rib.

Answer & Comments

Answer: 5- Increasing peripheral glucose
utilisation

Metformin is being used increasingly in
polycystic ovary syndrome (PCOS) and non¬
alcoholic steatohepatitis, two diseases that
feature insulin resistance.

metformin improves insulin sensitivity by
increasing peripheral glucose uptake and
utilization

[ Q: 2447 ] MRCPass - 2012 January

A 25-year-old man presents with sw
elling and pain in his left arm after exercising
in the gym. Symptoms started 75 minutes
after the exercises. The arm turned reddish,
and he described it as 'feeling different than it
ever had before'. On examination there was
no supraclavicular tenderness but when he
lifted his arm up the brachial pulse on the left
arm was absent.

What is the likely diagnosis?

1- Lower trunk brachial plexus lesion

2- Syringomyelia

3- Thoracic outlet syndrome

4- Neuralgic amyotrophy

5- Takayasu's arteritis

Answer & Comments

Answer: 3- Thoracic outlet syndrome

[ Q: 2448 ] MRCPass - 2012 January

A 32-year-old female presents
complaining of a purpuric rash on the back of
her legs and her buttocks. She has been
complaining of a sore throat and a productive
cough a week ago. She also has mild pains in
her elbow and knee joints. She has no
significant past medical history and has not
been on any medications recently. A urine
dipstick shows blood ++ proteins +. Her blood
results are:

Hb 11.3 g/dl
Platelets 155 x 10 9 /l
WCC 5.3 x 10 9 /l
PT 13 secs

APTT 30 secs

sodium 135 mmol/l

potassium 4.5 mmol/l

urea 5 mmol/l

creatinine 100 [imol/l

What is the most likely diagnosis?

1- Drug-induced thrombocytopenia

2- Henoch-Schonlein purpura

3- Idiopathic thrombocytopenic purpura

4- Thrombotic thrombocytopenic purpura

5- Systemic lupus erythematosus

Answer & Comments

Answer: 2- Henoch-Schonlein purpura

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This patient is likely to have Henoch-
Schonlein purpura (HSP), which is a self-
limited systemic vasculitis. It is suspected to
be triggered by an IgA-mediated response to
an antigen. It is characterized by 4 clinical
syndromes:

1. Palpable purpura in the absence of
thrombocytopenia or coagulopathy. Develops
in 100% of patients.

2. Arthritis/arthralgia in 45-75% of patients.
Second most common manifestation of HSP.

3. Abdominal pain in 50%, Gl bleeding (often
occult) in 20-30% of patients.

4. Renal disease in 20-50%.

ethnic population. The researcher is
concerned about the spread of blood
pressures being larger than in the general
population, hence affecting the sample mean.

Which of these measures provides an
estimate of this concept of uncertainty?

1- Sensitivity

2- Specificity

3- Positive predictive value

4- Negative predictive value

5- Standard error of mean

Answer & Comments

Answer: 5- Standard error of mean

[ Q: 2449 ] MRCPass - 2012 January

A 20 year old man drinks a litre of
beer and has polyuria.

Which one of these mechanisms leads to
polyuria?

1- Decreased glomerular filtration rate

2- Decreased Aquaporin action

3- Increased ADH secretion

Standard deviation provides a measure of
spread of observations about mean. It based
of deviation of each observation from the
mean value. Standard error of the mean is
the standard deviation of the sampling
distribution of the mean - which gives an
estimate of how close the sample mean is to
the true population mean. It increases with
sample size and increases with standard
deviation.

4- Increased atrial natriuretic peptide

5- Increased sodium absorption

Answer & Comments

Answer: 2- Decreased Aquaporin action

Aquaporins selectively conduct water
molecules in and out of the cell, while
preventing the passage of ions and other
solutes. There are several types of aquaporin
receptors, and aquaporin 2 absorbs water in
response to antidiuretic hormone and in this
case, the effect of Aquaporin 2 is decreased
leading to polyuria.

[ Q: 2450 ] MRCPass - 2012 January

A statistician is advising a research
about a study of blood pressures in a specific

The S.E.M. is the standard deviation divided
by the square root of the sample size SEM =
f? / ??N where f? is the standard deviation of
the original distribution and N is the sample
size.

[ Q: 2451 ] MRCPass - 2012 January

A 36-year-old woman was
commenced on nasogastric feeding following
significant weight loss. She has a history of
severe alcohol abuse. Three days later she
becomes very confused. On examination she
was apyrexial, appeared appropriately
hydrated, a pulse of 98 bpm pressure 96/60
mmHg.

Which one of the following investigations
should be done?

1- Bicarbonate

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2- Phosphate

3- Calcium

4- Magnesium

5- Potassium

Answer & Comments

Answer: 2- Phosphate

The patient has refeeding syndrome.
Refeeding malnourished patients increases
basal metabolic rate. This anabolic response
causes intracellular movement of minerals,
serum phosphate levels may fall significantly,
leading to cardiorespiratory compromise,
confusion and lethargy.

[ Q: 2452 ] MRCPass - 2012 January

A 50 year old man presents with
hearing loss and difficulty with balance and
gait. He is examined carefully by the
neurologist.

Which one of the following signs is consistent
with early presentation of acoustic neuroma?

1- Bitemporal hemianopia

2- Decrease in visual acuity

3- Loss of corneal reflex

4- Tongue deviation

5- Loss of gag reflex

reported tinnitus (most often a unilateral
high-pitched ringing, sometimes a machinery¬
like roaring or hissing sound, like a steam
kettle). Additionally, the classic description of
early trigeminal involvement with an acoustic
neuroma is loss of the corneal reflex.

[ Q: 2453 ] MRCPass - 2012 January

A 60 year old lady presents with
lethargy. On investigation the following
results were obtained:

Hb 7.8g/dl

WBC 3 x 10 9 /l

Platelet 90 x 10 9 /l

MCV 109 fl

Anti parietal antibody positive.

An endoscopy was performed.

Which area is most likely to sure abnormal
biopsy to confirm the diagnosis?

1- Proximal stomach

2- Distal stomach

3- Oesophagus

4- Duodenum

5- Terminal ileum

Answer & Comments

Answer: 1- Proximal stomach

Answer & Comments

Answer: 3- Loss of corneal reflex

Acoustic neuroma is a benign primary
intracranial tumor of the myelin-forming cells
of the vestibulocochlear nerve (CN VIII).The
earliest symptoms of acoustic neuromas
include ipsilateral sensorineural hearing
loss/deafness, disturbed sense of balance and
altered gait, vertigo with associated nausea
and vomiting, and pressure in the ear, all of
which can be attributed to the disruption of
normal vestibulocochlear nerve function.
Additionally more than 80% of patients have

The diagnosis is likely to be pernicious
anaemia because of the macrocytic anaemia
and positive anti parietal antibody. The
question refers to where atrophic gastritis
occurs. There are two types of atrophic
gastritis.

Type A gastritis primarily affects the
body/fundus (proximal) of the stomach, and
is more common with pernicious anemia.

Type B gastritis (most common overall)
primarily affects the antrum (distal), and is
more common with H. pylori infection.

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[ Q: 2454 ] MRCPass - 2012 January

A 36 year old man has presented
with back pains and joint pains over several
months. He has no other past medical history
to date. He mentioned that his father had a
history of joint problems. On examination,
there is no evidence of skin involvement.
Joint examination revealed evidence of
synovitis in the metacarpophalangeal,
metatarsal and wrist joints bilaterally limiting
his range of joint movements.

Laboratory testing revealed a C-reactive
protein of 0.33 mg/dl (<0.80 mg/dl), strongly
positive CCP antibody, IgG of 148 Units (<20
Units), and angiotensin-converting-enzyme
(ACE) of 73 U/liter (<67 U/liter). Anti nuclear
antibody (ANA), anti neutrophil cytoplasmic
antibody (ANCA) and rheumatoid factor (Rh
F) were negative.

What is the diagnosis?

1- Dermatomyositis

2- Psoriatic arthropathy

3- Rheumatoid arthritis

4- Osteoarthritis

5- Systemic lupus erythematosus

Answer & Comments

Answer: 3- Rheumatoid arthritis

Anti-citrullinated protein/peptide antibodies
(Anti-CCP) are autoantibodies frequently
detected in rheumatoid arthritis patients. It
has a sensitivity of 70% as a diagnostic test.
The positive anti-CCP antibodies and
symmetrical polyarthropathy without skin
involvement suggests rheumatoid arthritis.

Rheumatoid factor is an IgM antibody against
IgG. Some patients with rheumatoid arthritis
will have a negative rheumatoid factor, as in
this case.

palpitations which have been going on for 2
days. He has a past medical history of
hypertension and currently takes aspirin and
amlodipine. On examination he has a regular
pulse rate of 150.

The ECG shows a narrow complex

tachycardia.

What is the likely arrhythmia?

1- Atrial fibrillation

2- Atrial flutter

3- Atroventricular re-entry tachycardia

4- Atroventricular nodal re-entry tachycardia

5- Idioventricular rhythm

Answer & Comments

Answer: 2- Atrial flutter

The heart rate of 150 which is regular, narrow
QRS complex tachycardia is suggestive of
atrial flutter with 2:1 conduction. The atrial
flutter circuit usually runs at a rate of 300 per
minute and can present with 2:1, 3:1 or 4:1
conduction.

[ Q: 2456 ] MRCPass - 2012 January

A 28 year old patient presents to the
clinic for advice. His brother has recently
been diagnosed with haemochromatosis.

Which one of the following is the most useful
screening test?

1- Ferritin

2- HFE gene analysis

3- Ultrasound of the liver

4- Liver iron levels

5- Transferrin saturation

Answer & Comments

Answer: 5- Transferrin saturation

[ Q: 2455 ] MRCPass - 2012 January
A 55 year old man presents with

Transferrin saturation (TS) is the most
effective and inexpensive screening test for

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Fe overload. If the TS is > 45%, the test should
be repeated, together with serum ferritin. If
TS (w ith or without high ferritin) is raised,
HFE genes should be determined.

showed Polymorphic VT with constant
varying axis (Torsade de pointes).

What should be administered?

1- Flecainide

[ Q: 2457 ] MRCPass - 2012 January

A 46 year old lady has had moderate
redness in her right eye which is painless. She
has a long standing history of changes in her
hands and elbows consistent with
rheumatoid arthritis. Her ocular condition
had improved within a few days without
treatment.

2- Magnesium sulphate

3- Amiodarone

4- DC cardioversion

5- Na bicarbonate

Answer & Comments

Answer: 2- Magnesium sulphate

What is the likely diagnosis?
1- Glaucoma

Torsade is defined as a polymorphous VT in
which the morphology of the QRS complexes
varies from beat to beat.

2- Scleritis

3- Episcleritis

4- Keratoconjunctivitis sicca

5- Optic neuritis

Answer & Comments

Answer: 3- Episcleritis

Episcleritis is a relatively common benign
inflammatory condition of the eye. The
symptoms of the disease are usually self-
limiting, presenting in part with acute onset
of red eye. Episcleritis is often acute and
painless, whilst scleritis has more gradual
onset and very painful. Although most of the
cases are idiopathic, there is often an
underlying disease including rheumatoid
arthritis, polyarteritis nodosa, systemic lupus
erythematosus, sarcoidosis and Wegener's
granulomatosis.

with

[ Q: 2458 ] MRCPass - 2012 January

A 55 year old gentleman presents
dizziness. He was on various

medications. On examination his Blood
pressure was 110/68mm of Hg. The ECG

This was symbolically termed torsade de
pointes, or "tw isting of the point" about the
isoelectric axis.

The electrolyte disturbances that have been
reported to precipitate torsade include
hypokalemia and hypomagnesemia.

Torsade also is subject to degeneration into
ventricular fibrillation so therapy should be
started as soon as the rhythm clearly fulfills
the criteria for torsade. Treat hypokalemia if
it is the precipitating factor and administer
magnesium sulfate in a dose of 2-4 g
intravenously (IV) initially. Magnesium is
usually very effective, even in the patient
with a normal magnesium level.

^ [ Q: 2459 ] MRCPass - 2012 January

#1 -

0 A 21-year-old man presented to

A&E with fever for one day. On arrival, the
patient's BP was 109/50 mmHg, pulse rate
was 115 and temperature was 38.1°C. On
examination, there were generalised maculo-
papular rash.

Investigations showed a raised white cell
count of 18 with neutrophilia, raised CSF
protein of 5.45 g/L and decreased CSF glucose
of 0.1 mmol/L. CSF was turbid with

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predominating polymorphs and CSF culture
grew Neisseria meningitides. The patient has
close contact with 2 other housemates.

What prophylaxis should be given?

1- Penicillin

2- Flucloxacillin

3- Rifampicin

4- Isoniazid

5- Gentamicin

Answer & Comments

Answer: 3- Rifampicin

Those who have close contact with a patient
with meningococcal infection should have
prophylaxis. The current regime for
chemoprophylaxis includes oral rifampicin
600 mg every 12 hours for 2 days, a single
oral dose of ciprofloxacin 500 mg or
ceftriaxone 250 mg intramuscularly.

[ Q: 2460 ] MRCPass - 2012 January

A 65 year old patient with colorectal
cancer has been commenced on a
chemotherapy regime with Capecitabine and
oxaliplatin following surgery.

What is the main difference between 5 FU
and capecitabine?

1- Capecitabine is used orally

2- Capecitabine has a broader indication

cancers. It is a prodrug, that is enzymatically
converted to 5-fluorouracil in the tumor,
where it inhibits DNA synthesis and slows
growth of tumor tissue. Pancytopenia,
diarrhoea and hand-foot syndrome are main
side effects.

[ Q: 2461 ] MRCPass - 2012 January

A 61 year old lady presents with a
flu like illness and cough. She had not
improved despite amoxicillin prescribed by
the GP over the last week. On examination,
she had a temperature of 38 C and was
tachycardic. Respiratory examination and
chest X ray confirmed right middle lobe
consolidation. Antibodies to mycoplasma
pneumonia was sent and repeated a week
later, demonstrating increasing titres.

She is allergic to macrolides so she could not
be given erythromycin.

Which one of the following antibiotics is a
good alternative?

1- Ceftriaxone

2- Tazocin

3- Gentamicin

4- Linezolid

5- Doxycycline

Answer & Comments

Answer: 5- Doxycycline

3- Capecitabine causes peripheral neuropathy

4- 5 FU has less side effects

5- 5 FU interacts with warfarin

Answer & Comments

Answer: 1- Capecitabine is used orally

Capecitabine is the oral equivalent of
intravenous 5 -FU. Capecitabine (Xeloda,
Roche) is an orally-administered
chemotherapeutic agent used in the
treatment of metastatic breast and colorectal

The patient may have developed antibiotic
related diarrhoea. Mycoplasma infection can
be treated with macrolides (erythromycin),
ciprofloxacin and doxycycline. An antibiotic
with narrower spectrum of action here is
doxycycline.

[ Q: 2462 ] MRCPass - 2012 January

A 22 year old woman presents
bilateral leg weakness and numbness
following an episode of diarrhoea 2 weeks
ago. On examination, she has distal weakness

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in the hands and legs. Supinator and ankle
reflexes were difficult to elicit.

Which of the following should be used to
monitor her condition?

1- Postural blood pressure

2- Chest x ray

3- Vital capacity

4- PEFR

5- FEV1/FVC ratio

Answer & Comments

Answer: 3- Vital capacity

The patient has distal motor and sensory
nerve involvement following infection, hence
the likely diagnosis is acute inflammatory
demyelinating polyneuropathy (Guillain Barre
Syndrome). Vital capacity is used to monitor
for respiratory distress due to neuromuscular
weakness in Guillain Barre syndrome. Normal
values are usually 3-6 litres, varying with age,
gender and height.

[ Q: 2463 ] MRCPass - 2012 January

A 45 year old right- handed woman
presented with difficulty reading. She was
investigated with a CT brain which showed
right sided parietal lobe infarction.

The non-dominant parietal lobe is important
for visual spatial sensory tasks such as
attending to the contralateral side of the
body and space as well as constructional tasks
such as drawing a face, clock or geometric
figures. A non dominant lesion leads to visual
inattention and dyspraxia (unable to
coordinate motor tasks).

[ Q: 2464 ] MRCPass - 2012 January

A 36 year old African man with
known HIV infection presents with several
episodes of seizures. His CD4 count was 130
cells/mm * 1 2 3 4 when measured 1 month ago. On
examination, he had a temperature of 38 °C
and was confused with an MTS score of 5/10.
There were no focal neurological signs. He
had an MRI scan which shows multiple ring
enhancing lesions. CSF examination showed
an elevated protein count, lymphocytosis and
normal glucose levels. The CSF cryptococcal
antigen was negative. A chest X ray was
normal.

Which of the following is likely to be
contributing to her reading difficulty?

1- Agraphia

2- Amnesia

3- Left right disorientation

4- Visual inattention

Whot is the likely diagnosis?

1- Progressive multifocal

leukoencephalopathy

2- Cerebral toxoplasmosis

3- Cerebral lymphoma

4- Tuberculosis

5- Hemianopia

5- Bacterial meningitis

Answer & Comments

Answer: 4- Visual inattention

This patient is right handed, hence the left
brain is dominant, and the right parietal lobe
infarct is in the non dominant hemisphere.

Answer & Comments

Answer: 2- Cerebral toxoplasmosis

The likely diagnosis is cerebral toxoplasmosis
as there are multiple ring enhancing lesions.
Lymphoma usually causes single enhancing

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lesions and PML is less frequently ring
enhancing. Tuberculosis frequently causes
significantly low glucose levels.

Cerebral Toxoplasmosis

[ Q: 2465 ] MRCPass - 2012 January

A 36 year old woman lives alone.
She has been unable to work because she
begins to fear that the other co-w orkers are
plotting against her. She also fears leaving the
home, due to embarrassment. She has
become increasingly anxious and withdrawn,
and refused to eat with anyone else. Then she
began receiving mental messages when she
watched television, so she withdrew from the
living area as well. She was finally hospitalized
after she barricaded herself in her bedroom.

What is the diagnosis?

1- Obsessive compulsive disorder

2- Personality disorder

3- Paranoid schizophrenia

4- Bipolar disorder

5- Hypochondriasis

Answer & Comments

Answer: 3- Paranoid schizophrenia

This patient has paranoid feelings that others
are plotting against her and has emotional
embarrassment which is out of context. She
also has delusions, hence fits the diagnosis of
schizophrenia.

[ Q: 2466 ] MRCPass - 2012 January

A 60-year-old man has a history of
aortic stenosis. He developed symptoms of
shortness of breath and was referred into
hospital. On examination, he had a raised JVP,
bilateral basal crepitations in the lung and
moderate ankle oedema. He had a harsh
systolic murmur in the aortic area and a soft
second heart sound. The ECG showed sinus
rhythm with left ventricular hypertrophy. An
echocardiogram showed severe aortic
stenosis and heavy valvular calcification.
There was mild aortic regurgitation. Left
ventricular ejection fraction was 45%.

Which one of the following is the most
significant indicator of poor prognosis?

1- Aortic valve calcification

2- LVH on the ECG

3- Aortic regurgitation

4- Left ventricular failure

5- Atrial fibrillation

Answer & Comments

Answer: 4- Left ventricular failure

There are many factors to consider in the
assessment of aortic stenosis, the valve
gradient on echocardiogram, left ventricular
function, pulse character, and symptoms of
the patient. In the list of features above, the
most significant is the development of left
ventricular failure which suggests that the
patient is no longer able to compensate for
the severe aortic stenosis.

[ Q: 2467 ] MRCPass - 2012 January
A 40 year old man is reviewed 4

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weeks post renal transplantation. He has
been on ciclosporin and prednisolone.

What is the mechanism of action of
ciclosporin?

1- Inhibits prostaglandins

2- Inhibits action of IL-2

3- Antagonises tetrahydrofolate reductase

4- Phosphodiesterase 5 inhibition

5- Podophyllin inhibitor

Answer & Comments

Answer: 3- Acute hepatitis A infection

The abrupt onset of fever, fatigue, malaise,
anorexia, nausea, diarrhea, jaundice and
abdominal discomfort are consistent with
acute hepatitis A infection (especially history
of diarrhoea). Leptospirosis is less likely as
there is no renal involvement and infectious
mononucleosis does not usually cause
diarrhoea.

Answer & Comments

^ [ Q: 2469 ] MRCPass - 2012 January

Answer: 2- Inhibits action of IL-2

A 16 year old lady presented to the

Ciclosporin is a calcineurin inhibitor. It binds
to the cytosolic protein cyclophilin
(immunophilin) of T-lymphocytes. This
complex of ciclosporin and cyclophilin inhibits
calcineurin, which is responsible for activating
the transcription of IL-2.

[ Q: 2468 ] MRCPass - 2012 January

A 26 year old man has recently been
to India for a holiday, returning a week ago.
He presents with fatigue and abdominal
pains. He gives a history of diarrhoea for 5
days. On examination, he was jaundiced and
had tender hepatomegaly.

cardiology clinic for assessment. She had
been diagnosed with Turner syndrome. She
had normal early developmental milestones
but had multiple ear infections in childhood
and presented with primary amenorrhea
later. On examination, she had short stature,
cubitus valgus and a webbed neck. Cardiac
examination revealed a soft ejection systolic
murmur in the aortic area.

What is the most likely cause of the murmur?

1- Ventricular septal defect

2- Bicuspid aortic valve

3- Aortic stenosis

4- Pulmonary stenosis

His investigations show:

sodium 135 mmol/I, potassium 4.2 mmol/l,
urea 5 mmol/l, creatinine 100 pmol/l, ALT
1380 (5-35) U/l, AST 1430 (1-31) U/l, ALP 360
(20-120) U/l, GGT 320 (4-35) U/l, Bilirubin 35
(1-22) pmol/l, Albumin 35 (37-49) g/l

What is the likely diagnosis?

1- HIV infection

2- Leptospirosis infection

3- Acute hepatitis A infection

4- Acute hepatitis B infection

5- Infectious mononucleosis

5- Partial anomalous venous drainage

Answer & Comments

Answer: 2- Bicuspid aortic valve

Normal females have two X chromosomes,
but in Turner syndrome, one of those sex
chromosomes is missing or has other
abnormalities (XO). The most commonly
observed are congenital obstructive lesions of
the left side of the heart, leading to reduced
flow on this side of the heart. This includes
bicuspid aortic valve and coarctation
(narrowing) of the aorta.15% of adults with
Turner's syndrome have bicuspid aortic

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valves. 10% of patients with Turner's
syndrome have coarctation of aorta.

[ Q: 2470 ] MRCPass - 2012 January

# A 60-year-old man has developed
symptoms of shortness of breath and was
referred into hospital. On examination, he
had a hyperdynamic pulse, prominent carotid
pulsations and a displaced apex beat. He had
a grade 3 early diastolic murmur in the lower
left sternal edge.

What is the likely diagnosis?

1- Mitral stenosis

2- Mitral regurgitation

3- Atrial septal defect

4- Aortic stenosis

5- Aortic regurgitation

The organisms found most typically causing
ongoing infection in bronchiectasis include
Haemophilus species (47-55% of patients)
and Pseudomonas species (18-26% of
patients)

[ Q: 2472 ] MRCPass - 2012 January

Which one of these methods allows
the study of the 3D structure of protein?

1- Northern blotting

2- Southern blotting

3- Western blotting

4- X ray crystallography

5- Gel electrophoresis

Answer & Comments

Answer: 4- X ray crystallography

Answer & Comments

Answer: 5- Aortic regurgitation

A displaced apex beat, hyperdynamic and
collapsing pulse, prominent carotid pulsations
(Corrigan's sign) and early diastolic murmur
heard best in the lower left sternal edge are
signs of aortic regurgitation.

[ Q: 2471 ] MRCPass - 2012 January

A 36-year-old man who is known to
have bronchiectasis has a chronic cough. A
sputum sample is sent from the clinic.

What organism is most likely to be isolated?

1- Streptococcus pneumoniae

2- Klebsiella spp.

3- Haemophilus influenzae

4- Moraxella

5- Pseudomonas aeruginosa

Answer & Comments

Answer: 3- Haemophilus influenzae

X-ray crystallography is a method of
determining the arrangement of atoms within
a crystal, in which a beam of X-rays strikes a
crystal and diffracts into many specific
directions. The method can reveal the 3D
structure of many biological molecules,
including vitamins, drugs, proteins and
nucleic acids such as DNA.

The northern blot is a technique used in
molecular biology research to study gene
expression by detection of RNA in a sample.
Northern blotting involves the use of
electrophoresis to separate RNA samples by
size, and detection with a hybridization probe
(either DNA or RNA) complementary to part
gene sequence. The Western blot is a
technique involving electrophoresis to detect
specific proteins in the given sample of tissue
homogenate or extract (e.g. in HIV testing, or
to detect prions in Bovine Spongiform
Encephalopathy).

Northern blotting detects RNA and Southern
blotting detects DNA.

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[ Q: 2473 ] MRCPass - 2012 January

A 41-year-old lady was referred to
an endocrinologist for evaluation of a lump in
the neck. The patient reported a recent 5-kg
weight gain and difficulty sleeping and
lethargy. She mentioned that her mother has
a problem with hypothyroidism and her son
who is aged 10 has type I diabetes and is on
insulin.

On examination, blood pressure was 110/78
mm Hg, and resting pulse was 76 beats per
minute. Upon neck examination, a firm,
tender thyroid gland was felt, approximately
twice normal size, with the right lobe slightly
larger than the left. A thyroid uptake scan
showed a 24-h thyroid uptake of 32% and a
homogenous (but asymmetric) distribution of
isotope on thyroid scan, the right lobe
containing more isotope than the left.

Blood results: Free T3 was 4.5 (4.0-8.0)
pmol/L, Serum T4 was 5.4 ?g/dL (normal, 5-
12), serum TSH was 9.5 mU/L (normal, 0.4-
4.6). High titres of antithyroid peroxidase
antibodies were found. A fine needle
aspiration of the nodule was performed, and
it revealed a mixed population of lymphoid
cells, mainly small round and small cleaved
lymphocytes, with numerous plasma cells:

What is the diagnosis?

1- Papillary thyroid carcinoma

2- Post partum thyroiditis

3- Multinodular goiter

patient more likely to have Hashimoto's
thyroiditis.

A diagnosis of Hashimoto's thyroiditis is
usually made when positive antithyroid
peroxidase antibodies are present or
spontaneous hypothyroidism develops and
also low thyroglobulin antibody levels.
Hashimoto's thyroiditis is an autoimmune
disorder characterised by extensive
infiltration of the thyroid parenchyma by
lymphocytes and plasma cells, with the
formation of germinal centres. Classically,
presentation is with a goitre or
hypothyroidism or both. It is the most
common cause of sporadic goitrous
hypothyroidism in non-iodine deficient areas.
The thyroid may be barely palpable or greatly
enlarged. Characteristically, it is firm, and well
defined with an enlarged pyramidal lobe and
palpable neighbouring lymph nodes.

[ Q: 2474 ] MRCPass - 2012 January

A 36-year-old woman was admitted
to hospital with complaints of weakness, back
pain and difficulty walking.

She had been treated for epilepsy for 20
years, and was being on a combination
therapy of carbamazepine and valproic acid,
which she had been taking for approximately
10 years. The seizures were well controlled
with these drugs. She had a normal diet, was
independent and worked in a restaurant. She
had a normal social life.

4- Grave's disease

5- Hashimoto's thyroiditis

Answer & Comments

Answer: 5- Hashimoto's thyroiditis

In view of the family history of autoimmune
disease, the diagnosis here is likely to be
either Grave's disease or autoimmune
thyroiditis (Hashimoto's thyroiditis). The
associated hypothyroid picture makes this

Physical examination indicated that the
patient was well-built and had no skeletal
deformity. Neck and lumbosacral movements
were slightly limited. In laboratory
examinations, full blood cell count and renal
function were normal.

Biochemical analyses showed: serum alkaline
phosphatase (AP) 2670 U/L (normal 15-270),
calcium 2.10 (2.25-2.7) mol/l, albumin 4.6
g/dL (3.5-5.0), and phosphate 0.75 (0.8-8)
pmol/l. Serum 25-hydroxy (OH)-vitamin D
concentration was 7 ng/mL (10-40).

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Parathormone (PTH) concentration was 1371
pg/mL (12-72). X rays revealed minimal
narrowing and irregularity of the sacroiliac
joint, with marked osteoporosis and
biconcave vertebrae.

What is the underlying cause?

1- Dietary vitamin D deficiency

2- Decreased sun exposure

3- Chronic inactivity

4- Chronic renal failure

5- Drug induced osteomalacia

Answer & Comments

Answer: 5- Drug induced osteomalacia

Based on the history of prolonged
anticonvulsant use, low serum calcium, and
25-OH-vitamin D concentrations with high
PTH, the most likely diagnosis is
anticonvulsant-induced osteomalacia.

atrophy bilaterally and also gynaecomastia.
There was also sparse facial and body hair. A
series of blood tests were conducted
revealing the following results;

prolactin concentration 320 mu/I (50-450)

testosterone 4 (11-36) nmol/L

LH 6 (0.5-9) IU/L

FSH 3 (1-8 ) IU/L

Early morning cortisol 500 (130-690) nmol/L
What is the likely diagnosis?

1- Klinefelter's syndrome

2- Hypopituitarism

3- Kallman's syndrome

4- Achondroplasia

5- Turner's syndrome

Answer & Comments

Answer: 1- Klinefelter's syndrome

A normal social life and employment suggests
normal amounts of sun exposure.
Hypocalcemia, increased serum alkaline
phosphatase, and decrease in the 25-OH-
vitamin D concentrations are hallmarks.
Phenobarbitone, phenytoin, carbamazepine
and also sodium valproate can cause
osteomalacia.

25-OH-vitamin D (alphacalcidol 1.5 ?g/d) and
calcium (elementary calcium 2 g/d)
supplementations should be initiated.
l,25(OH)2 vitamin D is more difficult and
expensive to measure than 25(OH)D;
moreover, it is not a good measure of vitamin
D status.

[ Q: 2475 ] MRCPass - 2012 January

A 25 year old man has presented for
evaluation for right sided gynaecomastia. He
has had a mastectomy on the left side 2 years
ago and is concerned that it is now recurring.
Physical examination revealed a slim tall man
with a height of 1.86 m. There was testicular

Klinefelter's syndrome (XXY) causes testicular
atrophy, which commonly leads to
gynecomastia and infertility.

Androgen deficiency (in this case low
testosterone) causes eunuchoid body
proportions; sparse or absent.

facial, axillary, pubic, or body hair; decreased
muscle mass and strength; feminine
distribution of adipose tissue; gynecomastia;
small testes and penis. Most 47,XXY males
have normal intelligence.

The blood tests show normal levels of LH and
FSH hence making this unlikely to be
Kallman's syndrome (hypothlamic
gonadotrophin releasing hormone deficiency)

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